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  • Medicine as a government benefit.

    Posted by Michael Kennedy on August 3rd, 2014 (All posts by )

    Obamacare is having serious trouble as I have discussed. The success stories, like California, are an example of what I have called Medicaid for All.

    “It’s a total contradiction in terms to spend your public time castigating Medicaid as something that never should have been expanded for poor people and as a broken, problem-riddled system, and then turn around and complain about the length of time to enroll people,” said Sara Rosenbaum, a member of the Medicaid and CHIP Payment and Access Commission, which advises Congress.

    Most of the new enrollees are Medicaid members and those enrolled in “private insurance” learn that they have severely restricted choice of doctor or hospital.

    Now we have a new development.

    John Foust, a Democrat running for the 10th congressional seat in Northern Virginia, is — like Gov. Terry McAuliffe and other state Democrats — gung-ho to expand Medicaid. His wife’s position is, shall we say, a bit more nuanced.
    Foust has slammed his opponent, Republican Del. Barbara Comstock, for her opposition to expansion. He has spoken of the need to “make health care available to 400,000 Virginians,” insisting it is “the right thing to do.”
    Foust’s wife, Dr. Marilyn Jerome, practices with Foxhall OB/GYN in northwest Washington, D.C. Six of its physicians made Washingtonian magazine’s list of “Top Docs, and one of them — Nichole Pardo — was featured on the cover. Not too shabby.

    The practice is notable for another reason as well: It doesn’t accept Medicaid patients.

    Now what ?

    On his website, Foust blasts insurance companies that “hiked insurance premiums and gouged consumers. … Insurance companies denied care to those with pre-existing conditions … and refused coverage to those who needed it most. … We cannot go back to the days when insurance companies could arbitrarily … deny coverage.” In a commentary on the Foxhall practice’s website, Dr. Jerome praises the Affordable Care Act — particularly because now “women cannot be denied insurance” and because the plan’s standards mandate coverage for a wide variety of treatments.
    Doctors, however, can operate under a much different set of standards. They can deny care all they want. Statewide, roughly one in five physicians will not accept new Medicaid patients — usually because Medicaid pays only two-thirds as much as private insurance does, on average.

    My experience, which is 20 years old, is that Medicaid (MediCal in California) pays a lot less than 2/3 as much and it takes two years to get that.

    Abiding by the individual mandate therefore constitutes what President Obama, in another context, recently called “economic patriotism.” He was castigating companies that use overseas mergers to avoid U.S. taxes. “You know,” he said, “some people are calling these companies corporate deserters.”
    Ominous language. Treating private enterprise as a conscript in service to the State is a philosophy with an ugly lineage. In liberal democracies, government is supposed to be the servant — not the master. In health care, however, the relationship is growing increasingly inverted. As a result individuals are forced to buy insurance, and insurance companies are forced to accept them. Now many people want to force drug companies to cut prices. And so on.
    Forcing doctors to accept Medicaid patients would be an obvious, logical extension of these trends. If insurance companies can’t turn people away, then why should physicians be allowed to?

    Yes, indeed. This sort of legislation has been introduced in Massachusetts.

    [Senate bill 2170 and house bill 4452] would require physicians and all other health care providers to accept 110% of Medicare rates for health insurance for small businesses. For physicians, acceptance of set rates would be as a condition of licensure! Moreover, physicians would have to accept all such patients – and such rates – if they participate in any other plan offered by that insurer.

    They are not yet law but it may be coming.

    That is not the only problem for medical availability in the future.

    FRIDAY, Aug. 1, 2014 (HealthDay News) — A majority of categorical general surgery residents seriously consider leaving residency, according to a study published online July 30 in JAMA Surgery.
    Edward Gifford, M.D., from the Harbor-UCLA Medical Center in Los Angeles, and colleagues anonymously surveyed 371 categorical general surgery residents from 13 residency programs and compared results based on whether or not respondents seriously considered leaving surgical residency. Ten-year attrition rates for each program were also evaluated.
    The researchers found that 58.0 percent of respondents seriously considered leaving training. Sleep deprivation on a specific rotation (50.0 percent), an undesirable future lifestyle (47.0 percent), and excessive work hours on a specific rotation (41.4 percent) were the most frequent reasons for wanting to leave. Residents didn’t leave because of support from family or significant others (65.0 percent), support from other residents (63.5 percent), and perception of being better rested (58.9 percent). Serious thoughts of leaving were tied to older age, female sex, postgraduate year, training in a university program, the absence of a faculty mentor, and lack of Alpha Omega Alpha status, although only female sex was significant upon multivariate analysis (odds ratio, 1.2; P = 0.003). High-attrition program residents were more likely to seriously consider leaving residency (odds ratio, 1.8; 95 percent confidence interval, 1.0 to 3.0; P = 0.03).
    “Thoughts of leaving seem to be associated with work conditions on specific rotations rather than with overall work hours,” the authors write.

    General surgeons are already in short supply. I get emails all the time offering jobs for general surgeons. In contrast to the days when I was in training, general surgery is now a relatively low paid specialty. The artificial joint and cataract surgery options did not exist in 1972.

    Welcome to the future. The comments to that article (It’s in an MD only forum) are interesting. Lots of complaints about hours and status. Less about money but some about money vs hours. Medicine is a lot less attractive now than it was 50 years ago but the population is aging. Also, women in medicine, as I expected, work less than men or than us oldsters did.

    This will not help.

    The company knew going in that the learning curve would be steep. It held focus groups last year with nearly 2,000 people and found, for example, that virtually none knew what coinsurance was. (It is the percentage a patient pays for some covered services.) The insurer is putting together a second round of focus groups to see if “we closed the gap any compared to last year,” Ms. Sunshine said.

    This is obviously not the group that lost their individual plans last year. All Medicaid.

     

    5 Responses to “Medicine as a government benefit.”

    1. dearieme Says:

      These things being discussed are all far more socialist than the NHS. “For physicians, acceptance of set rates would be as a condition of licensure!” Good grief.

    2. MikeK Says:

      The NHS is divided between GPs and specialists. The GPs in the British system do fairly well. There was a big issue in the beginning about sale of practices which was the pension system of GPs before the NHS. Specialists have always done fairly well. The problem is overwork. Many GPs have multiple revenue streams, what they call “diddles.” They are school physicians and have various outside jobs which means that patients must compete for their time with other activities. I got to know a little bit about it when I was a consultant from Dartmouth in 1995. I think there have been changes since then. At that time, they made quite a bit from vaccine companies, for example.

    3. dearieme Says:

      Getting licensed is quite independent of whether a doctor works for the NHS or not: the licence says you are competent to practise – it implies nothing about your employment or self-employment.

      “I think there have been changes since then”: you bet. In what must be one of the most incompetent act of government bargaining of my lifetime, the Blair government exempted GPs from their 24-7 responsibility for patients in return for a tiny pay cut; since they were separately giving them a ludicrously large pay rise, the GPs grabbed the offer with both hands. Afterwards the BMA (doctors’ union) negotiator said that they had had trouble at first understanding the government’s offer, so ludicrously extravagant had it been. Of course, high pay means a high pension, so over the next few years lots of GPs took early retirement. So a higher pay package brought about a shortage of workers – brilliant, eh? It’s one of the lesser reasons why we should impeach and hang Blair, but I’d have it on my list.

    4. Xennady Says:

      Many years ago I read a book- I forget the title, alas- that made the case that freedom in Medieval Europe came about because the established rules of a society comprising feudal manors and the church weren’t able to be applied in the towns that eventually grew into importance.

      I mention it here because it seems to me we have the opposite occurring- tyranny is growing in the spaces not covered by the rules of our established society, many of which were written to explicitly to prevent it.

      The relevant example here is the idea that doctors can be forced to provide services that they don’t want to provide, as a condition of remaining doctors.

      My immediate reaction is that this violates the Thirteenth Amendment banning involuntary servitude- but my guess is that the response of the folks who are sponsoring that law in Massachusetts would be to say that they’re not slaves, because they can always just stop being doctors, by giving up their licenses- and in any case they’re only forced to provide services for a discount.

      Neat, huh? Doctors can be compelled into servitude for the convenience of the state, essentially at gunpoint, but it’s only a little bit of servitude.

      For now.

      I suppose I’m an outlier to most people but I’m always amazed at just how much of the human interaction and economic activity in the present United States that occurs solely because of gunpoint compulsion by the government. The process has gone on for so long, and so unnoticed, that people can propose a law to force doctors- yeah, you know- and I bet they’d be astonished to hear that anyone found their proposed law tyrannical.

      Tyranny, growing in the margins, as freedom once did.

      It won’t end well, as that cliche famously notes.

    5. ErisGuy Says:

      “Will mandates for doctors come next?”

      Whatever makes you think you can be free under socialism?

      “It won’t end well, as that cliche famously notes.”

      Maybe not, but it won’t end soon either. The formerly Christian West is being transformed into a new civilization, with new ideas about politics, morality, religion. It’s easy enough to point out the winning ideas and losing ideas. In a generation or two, the number of believers in the old ways (freedom*) will be gone.

      * When a people freely choose who are their leaders, the result is democracy; when a people freely decide what is knowledge, the result is science; when a people associate and trade freely, the result is capitalism.