Over at Firedoglake a writer named "Scarecrow" attempts to convince that the 1990 page behemoth House health care bill unveiled this morning doesn't go far enough in expanding Medicaid coverage. Rarely have I seen something so clueless on the day to day economics of medicine for those who work in the field. There's a lot of talk about government policy, and all it does is to obscure the issue of service, as in, will it be available?
So, in order to protect private insurers from competition from a lower-cost PO and avoid paying providers Medicare rates plus 5 percent, which Blue Dogs think is too low, the House bill would pay providers even less (or no more*) than Medicare and take more than 3 million people completely out of the private market.
But of course, the market carve-out for Medicaid saves money, which means that if Blue Dogs really wanted to save money, they would enlarge the Medicaid carve out — say, up to 250 or 350 percent of FPL. In other words, if the fiscal-deficit scolds were genuinely serious about reducing the cost of the reform bill, they would expand eligibility to public health care to a lot more people and forget about shielding private insurers from competition.
But then they’d be accused of creating a powerful argument for Medicare for all, and we can’t have that. Because as Joe Lieberman reminds us, those government entitlement programs just increase the deficits — uh, except when they lower them.
Deficit, schmeficit. Maybe if we cut the rates to half of Medicaid levels we can have years with a surplus! Scarecrow adds an update; it doesn't help any.
* Update: A provision in the earlier House bills would increase Medicaid payments to match or come close to Medicare payment levels. If this provision is still in the revised bill, it should mitigate concerns that Medicaid payments will unduly discourage providers from treating more Medicaid patients.
Oh, that's much better. As a provider, out there trying to keep my own practice alive, pay my employees appropriately and have their own pay keep up with inflation (at a minimum), deal with rising supply costs, rising bureaucracy costs, rising health care costs, and rising overhead, Medicare and Medicaid don't cut it. Doctors drop Medicare because they can't pay the bills on Medicare patients, and Medicaid pays significantly less. Scarecrow looks at the governmental macroeconomics of health care reform rather than the effects on medical practices, seeing the forest but missing the trees. And I think that is what a lot of legislators in Washington are doing, and they're missing the individual trees. This isn't just a game where if you shift dollars around from pocket to pocket they multiply miraculously.
It's difficult enough to become a doctor, what with an extra four years of school, an extra 3 to 6 years of residency and then fellowship training, and then face the gradual buildup of a practice as your community slowly becomes comfortable with you as the go-to person when they find themselves in need. If the payoff after all that effort is that you'll annually be at risk of bankruptcy based on which way the country's breezes are blowing, then fewer and fewer bright, motivated individuals will make the effort - and delay their gratification - to get there. Oh, and there'll be vultures circling overhead watching every move, ready to swoop in for their pound of flesh, because we can't have tort reform, either. Better to go get that MBA or JD and see a light at the end of the tunnel.
Are all the doctors going to leave? No, because true altruism will motivate some, scientific interest will motivate others, and the fact that medicine is a relatively recession proof and permanent employment will motivate others. But that won't be enough to replace those who leave and also keep up with a growing population with growing medical needs. The places that will be hardest hit will be poor areas, and rural ones.
A lot of physicians chose to go into "the family business," as the sons or daughters of physicians themselves. This is true for me and two of my partners. And I can tell you that none of us are recommending that our children follow in our footsteps. Mine are still too young, but of the other two partners none of their six kids have done it.
So keep arguing about Medicaid rates, maybe moving them closer to Medicare (gasp!), and shifting costs onto the states by expanding Medicaid (the states love this), or "public options" dictating Medicare rates, or maybe (gasp!) Medicare +5. In twenty years there'll be a tremendous wait for physician appointments, particularly for specialists, waits for elective surgery like hip replacement, and waits for testing like MRI. The engineering world may develop some marvelous breakthroughs but nobody will be able to afford them. Oh, except for members of congress, because they are special, and the very, very wealthy. And people (like me) who know doctors in the system, as Gwendolyn pointed out yesterday. We'll know who to talk to; we'll get to the head of the line.
In The Blues Brothers the leader of The Good Ol' Boys band, whose gig Jake and Elwood stole at Bob's Country Bunker, told Jake when he asked for their union cards that "You're going to look pretty funny trying to eat corn on the cob with no f*in' teeth." Well, keep punching out the doctors and twenty years from now you're going to look pretty funny trying to get your knee replaced. Get on the list, and wait.
On the other hand, I guess the good news is that doctors won't be in the upper echelons of income anymore, so they won't have to pay the surtax on the wealthy that'll fund these Medicaid rates.