The Doctor-Patient-Government Relationship

The dismal outlook for the healthcare industry under ObamaCare.

With respect to medical care, far too many Americans make assumptions that have no basis in reality. Two of the most pernicious ones will be greatly exacerbated now that the Affordable Care Act has been ruled constitutional. The first assumption is the idea that having health insurance is the equivalent of having healthcare itself. The second assumption is the idea that doctors will be beholden to the interests of individual patients above all else. Both assumptions are wrong.

First, having health insurance means nothing more than having the ability to pay for one's health coverage. Coverage itself depends on having access to health professionals. With respect to that reality the numbers don't lie. The most concerning reality is the additional number of people who will be getting insurance under Obamacare. CNN estimates that number to be 32 million. In addition, another 15 million Americans will become eligible for Medicare in the coming years. At the same time, the United States is experiencing a physician shortage. According to the Association of American Medical Colleges (AAMC), it is a growing phenomenon. By 2015, they estimate there will be a shortage of 63,000 doctors. That number balloons to 91,500 by 2020, and 130,600 by 2025. “The new AAMC projections reflect what happens with a relatively sudden increase in physician demand,” said Scott Shipman, M.D., M.P.H., senior researcher of workforce studies at AAMC. “From a projection standpoint, there is an exacerbated shortage in all areas.”

In 2006, the AAMC called for a 30 percent increase in medical school enrollment. The actual increase amounted to 13 percent. They further note that without an increase in Graduate Medical Education Slots (GMEs), increasing the number of doctors becomes impossible. Obamacare will redistribute a number of unused residency slots. It will also increase funding for the National Health Service Corps, an entity that put resident physicians and other healthcare professionals in health professional shortage areas (HPSAs). As of September 2009, about 65 million people were living in HPSAs -- meaning they were already having trouble accessing healthcare. Yet increasing residency slots cost federal dollars, in addition to the cost projections for Obamacare that have already doubled since the law was passed.

Furthermore, medical school costs, which have long outpaced the cost of living, now top $250,000. Such costs are one factor driving medical students into medical specialties, rather than primary care medicine, which saddles would-be physicians with longer hours, less pay, and more administrative problems. That reality has also taken its toll: the number of U.S. medical school students going into primary care has dropped 51.8% since 1997, according to the American Academy of Family Physicians (AAFP). Since primary care doctors represent the front line in medical care, most people will be forced to wait far longer to see a "family doctor"--if they can find one at all.

And those are the people who still want to become, or remain, doctors. According to the St. Louis Front Page: "Despite the projected need for health care practitioners at all levels in a challenging job market, nearly half of high school-age students (45 percent of 13 to 18 year-olds) are not considering pursuing a career in health care and science fields." Even more frightening, a survey conducted by the Doctor Patient Medical Association reveals a staggering 83 percent of current doctors are thinking about leaving the profession when Obamacare is fully implemented. That is likely an exaggerated number, but the trend is unmistakeable. Moreover, an increasing number of physicians are refusing to take new Medicare patients, because low reimbursement rates--which could go even lower--make it harder to stay in business. "Physicians are saying, 'I can't afford to keep losing money,'" said Lori Heim, president of the American Academy of Family Physicians.

Add up the above factors and one thing becomes crystal clear: the assumption that health insurance guarantees timely access to health care is nothing more than a pipe dream.

Which brings us to assumption number two. The traditional doctor-patient relationship is based on the idea that a doctor’s fundamental responsibility is to practice medicine for his individual patient’s benefit. Or at least it used to be. In 2002, the American College of Physicians published a charter declaring that the medical profession "must promote justice in the health care system, including the fair distribution of health care resources." A 2011 article published in the New England Journal of Medicine declared that “the primacy of patient welfare” should be replaced with a system in which "physicians are collectively caring for a defined population within a fixed annual budget..." In other words, individual health considerations are trumped by those that benefit the collective.

And lest anyone thinks Obamacare mitigates that reality, think again. Obamacare authorizes the creation of an Independent Payment Advisory Board (IPAB) consisting of 15 unelected "experts" tasked with keeping Medicare spending under control. If Medicare spending exceeds predetermined targets, the IPAB is required to propose legislation aimed at reducing future spending. It also requires the Secretary of Health and Human Services to implement those reductions, unless Congress intervenes. Yet Congressional intervention is decidedly lopsided. If they introduce cuts to spending, all well and good. On the other hand, if they introduce spending in excess of the IPAB's recommendations, overturning those recommendations requires a simple majority in the House -- but a three-fifths majority in the Senate, plus the president’s signature. In the Senate, that's a higher threshold than it takes to pass a Constitutional amendment.

Obamacare ostensibly prohibits the IPAB from raising taxes or rationing care. But the board itself gets to define "rationing" completely insulated from administrative or judicial review. The prohibition on raising taxes is equally meaningless. Adding insult to injury, the editors at National Review have discovered that Congress is forbidden to repeal the IPAB unless it does so within a brief time-frame in 2017. If it doesn't, then the IPAB becomes a permanent fixture by 2020 -- even if Congress repeals the healthcare act. This is a blatant attempt by Democrats to bind future Congresses to the current statute. That effort is completely illegal. Yet barring a Republicans sweep in the 2012 elections, or at the latest, the 2016 elections, the IPAB will become a permanent feature of American healthcare.

How does this bode for the doctor-patient relationship? Dr. Jill Vecchio illuminated that reality at an anti-Obamacare rally hosted by Americans For Prosperity on June 29, 2012:

According to the government, I can only recommend a screening mammogram for women over 50 every other year until 74, then never again. That violates the American Cancer Society guidelines...The American Cancer Society says every year after the age of 40 until the woman no longer wants to have a mammogram.

Screening mammography has been proven to decrease the number of women who die by breast cancer by 30-40 percent--just screening mammography. These government rules that I will have to abide by will cause me to violate my Hippocratic Oath. And I won’t do it. I will violate their guidelines every day, many times a day. As a result of that..I will be fined, I won’t be paid[.]

In other words, many doctors will face a nightmarish choice: do I incur the wrath of government bureaucrats and practice medicine in the best interests of my patients--or succumb to a system where bureaucratically determined cost considerations override patient necessities? A third option is obvious: many doctors will quit practicing medicine altogether. As for the doctors willing to remain in such a system, Americans might ask themselves how eager they are to be treated by someone willing to betray a patient's best interests in favor of government-mandated rationing and collectivism.

Under Obamacare the doctor-patient relationship will inevitably become the government-doctor-patient relationship -- in precisely that order of priority. Thus, assumption number two is a fraudulent as assumption number one.

Both assumptions, like so many other issues, reveal the bankruptcy of progressivism. It is an ideology that assumes most human behavior is static rather than dynamic. Only a progressive could believe that the vast majority of doctors will continue to practice their craft under increasingly onerous conditions, or that equal numbers of would-be doctors will continue to pursue a career path underscored by ever-increasing amounts of medical school debt, coupled with fewer opportunities for remuneration and autonomy. Only a progressive could fail to see how an American public infused with greater and greater levels of self-entitlement won't overwhelm the system when healthcare becomes "free." Only a progressive could fail to see that yet another massive entitlement program will contain precisely the same "unforeseen" cost explosions that have plagued every entitlement program ever enacted, thereby hastening our rendezvous with national insolvency.

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