The Free Press, Mankato, MN

August 18, 2012

Our View: Will health care reform create tiers for care?


The Free Press

—  The law of unintended consequences contains historical examples of what can develop out of the blue when a particular social initiative is derived. Call it nature’s own “Whack A Mole” — while you hit on something to bring it down, up pops something else.

For instance, when Prohibition was developed in the 1920s to rid the nation of the effects of rampant alcohol abuse, it also stripped the governments of greatly needed revenue from taxes on alcohol. To make up for that loss, the nationwide income tax was instituted. Prohibition ended but not the income tax.

John Goodman of the National Center for Policy Analysis wrote recently that as a result of the Affordable Care Act that will add 30 million people to the health care system, not only will there be a rise in the average wait time to see a family doctor but a rise in “concierge medicine” for those who can afford it all because of one simple economic law: supply and demand.

Goodman writes there are not enough doctors available now to see those who have health insurance or Medicare. He points to a 2009 study that found the average wait for a new family doctor is just less than three weeks. However, in Massachusetts which has a similar health care law enacted by then Gov. Mitt Romney, the wait is about two months.

The original ACA bill did have funding for increased doctor training but was taken out.

However, the procedures health screening and preventive testing remained in ACA that Goodman argues will only increase the time demand on existing doctors, and that demand will mean doctors will increasingly first see those patients who pay the highest fees.

He points to a New York Times survey of dermatologists in 2008 that found a typical wait for Medicare patients was about two to three weeks. However, for treatments not covered by Medicare, such as Botox, or those patients paying market price were able to see doctors on the same day.

He further argues that with physicians having to allocate their time, there will be longer waits for the elderly and disabled on Medicare, low-income families on Medicaid and — conversely — those who would be covered under the new ACA health plan.

Goodman predicts the rise of concierge medicine where patients with means will pay doctors to be their agents rather than insurance companies.

That additional time spent will mean fewer patients will be seen, putting an even greater demand on those few physicians in the medical stream. The fault in Goodman’s analysis is his prediction that the medical community will operate much the same way it has. The reality is change is already under way and being led by respected health organizations such as the Mayo Health Clinic.

Fundamental changes are happening — even if ACA is repealed — that acknowledges health care costs need to be reined in. One method is finding ways in which someone other than a doctor will always be the primary care giver no matter what level of care is needed.

For instance, why must a doctor be available for preventive screening? Why not a physician’s assistant or senior nurse? Why must each hospital have its own neurosurgeon when modern technology can provide long-distance assistance with specialists not commonly available in non-metro areas?

Even before ACA, there were changes being developed within some medical communities that saw an increasing demand coming from an aging boomer population — the prime time when the need for medical care increases. Will doctors warm to the idea they no longer are the primary decision maker? Will there be enough physician assistants to fill the breach? We already know there are not enough nurses in the pipeline because there are not enough nursing educators to train them. Will there be unforeseen consequences with ACA if it survives? Most certainly, but there are unforeseen consequences coming even if ACA is repealed. We are experiencing longer life spans, increased medical technology, a massive increase in aging population, and all of that is forcing significant changes in medical care that have never been tried before.

When you have multiple solutions being created separately by governments and by the medical community in an anticipation of future needs that even patients are unsure of, the result is not something that can be crafted with any certainty.

Patients need to be well informed, governments and the health community must collaborate more and transparency of such involvements is necessary to ensure the impacts of special interests on the outcome are not skewed toward creation of unintended consequences.