Wednesday, October 9, 2013

The "Doctor Shortage" Argument Against Obamacare


You've all heard it before: Obamacare will exacerbate our already very limited supply of primary care doctors by creating an influx of new patients. As a result, wait times will significantly increase for all manner of routine procedures and medical appointments. Okay, there's nothing per se wrong with this argument, but it really begs another question: "how is this problem any more specific to Obamacare than, say, a conservative's idea of health care reform that also insures more people?"

Think about it: doctor shortages happen for one of two reasons. The first reason is that there are too few doctors. The second is that there are too many patients per doctor. In both instances there's a shortage and longer wait times. No one really disputes that fact. No one being honest, anyway. But here's where I have a problem with this thinking: people are using it as an argument against Obamacare, when the reality is that any law that increases the number of insured people would lead to longer wait times.

Put another way, let's say that we instead implemented a conservative idea for health reform that also allows 30 million more people to afford health insurance. Wait times would be longer then, too. It has precisely nothing to do with how people get insured and precisely everything to do with the number of people who are insured in relation to the number of doctors we have. Indeed, imagine this scenario Aaron Carroll thought up:
"We could convert the entire country to Medicare tomorrow, increase the number of physicians, and have no wait times at all. We could convert the entire country to private insurance in a Switzerland-like system, make no changes to the number of physicians, and see wait times go through the roof."
Now, don't misinterpret what I mean here--I'm not saying this is a non-issue, not by any means. It is a problem, and a very serious one at that. But if you, like me, think that people having access to health insurance is not only morally right but also economically beneficial, then the solution to the doctor shortage is not to keep more people from getting proper medical care, but to increase the number of people able to disburse that care. You see, the U.S., in spite of spending way, way more than other countries on health care, has a lot fewer primary care doctors:



It should be come clear rather quickly that we're lagging far behind in this metric by world standards. I'll allow my past self to explain why
"I don't like the American Medical Association. I don't like them because they've spent most of the past 20 or 30 years lobbying state medical licensing boards to restrict the number and size of medical schools due to a supposed over-supply of doctors (which was controversial in the first place). Moreover, they've also worked to significantly limit the number of foreign doctors who can come practice in the U.S. With a restricted supply of physicians, doctors have higher salaries, thus we pay more for medical care. Worse yet, most of the already limited supply of physicians coming out of medical schools, for a variety of reasons, want nothing to do with primary care, which is arguably the most important form of health care."
So now that we've identified at least part of the problem, what can we do to fix it? Besides throwing the uninsured under the bus, I mean. True, the Affordable Care Act does take modest steps to increase the salaries of primary care practitioners (PCPs) in an effort to boost the number of medical students becoming general practitioners, but that's hardly sufficient in the face of such a daunting problem. 

The solution to this problem--and indeed the whole reason I wrote this post--might be found in the pages of California's SB 493, which was signed into law last week. What this law does is it takes an important step in rolling back the often pernicious effects of medical licensing cartels like the AMA--it grants the state's many pharmacists PCP status. That means more doctors, more appointment slots, and shorter wait times.

Indeed, there are 18 other states in the U.S. that have done something similar by allowing Nurse Practitioners to be PCPs. Even more encouraging was the fact that they found that there was no significant decline in the quality of care resulting from this decision. The great irony here, though, is that the right to grant different medical professionals PCP status rests exclusively with state governments, which means that they're the ones who will have to step up to the plate and fight the doctor's shortage exacerbated by a federal law.

But the fact remains that something substantial can be done to fight it, and it seems disingenuous at best and downright cruel at worst to suggest that the uninsured must continue to suffer through their lives without proper medical care because of a largely solvable problem.