Public health care systems destroy health care
David Balat is the Director of the Right on Healthcare initiative with Texas Public Policy Foundation, 7-11, 20, https://thehill.com/opinion/healthcare/506901-oh-canada-should-the-us-emulate-canadas-national-health-service, Oh, Canada: Should the US emulate Canada’s National Health Service?
Oh, Canada: Should the US emulate Canada’s National Health Service? While progressives in the U.S. continue to push for government-run health care, the Province of Alberta’s government this week cleared the way for a health omnibus bill that seeks to privatize its health care system. The Canadian system is often touted as a model for the U.S. to follow; Sen. Bernie Sanders, for example, applauded the Canadian system during a presidential debate. But although the health care system in the U.S. needs much improvement, it’s very telling that the Canadian system is seeking to be more like ours. The Health Statutes Amendment Act, Bill 30, “proposes to cut approval times for private surgical facilities, allow the ministry to contract directly with doctors — and allow private companies to take over the administrative functions of physician clinics.” The bill addresses three longstanding problems in the Canadian system: Long wait times for surgeries, too-short visits with medical professionals, and the presence of too many middlemen. Yet these are just some of the systemic problems of the Canadian healthcare system. According to Health Minister Tyler Shandro, the move to privatization this year will allow doctors to “focus on providing care instead of focusing on administration,” which is really what health care should be about. The lesson for Americans in Canada’s health care troubles is that monolithic, single-payer systems don’t work, and the reforms we seek should be more market-oriented. The health care industry in the U.S. is far from a free market environment — which is evident in the fact that pricing is largely kept hidden from patients and employers. Price signals are critical for a free market to function. Without them, costs will continue to rise, and middlemen will have free rein to manipulate supply and demand. Four U.S. senators recently unveiled a bill that would make health care pricing more transparent. Sen. Chuck Grassley (R-Iowa) and his colleagues say that “This legislation would codify the two health care price transparency rules that came out of President Donald Trump’s ‘Improving Price and Quality Transparency in American Healthcare’ Executive Order — which requires hospitals and insurers to reveal their low, discounted cash prices and negotiated rates to consumers before they receive medical care.” These new price transparency regulations were important long before the COVID-19 pandemic, but in the aftermath of the economic disaster caused by the government shutdowns, “they’re a crucial first step toward engaging market forces to empower patients to access quality care at a lower cost.” Another systemic failure of the U.S. health care industry is the misalignment of incentives. Usually in free market systems, the person receiving services is also the one that pays for those services. Health care doesn’t function this way. Ever since the wage freezes of 1942 enacted by President Franklin D. Roosevelt, health insurance in the private sector has been tied to employment. Ironically, this progressive initiative is the root cause of what is known today as “pre-existing conditions.” Individuals, not corporations, should own their benefits and have them as portable to eliminate any risks associated with underlying medical conditions. Sen. Ted Cruz (R-Texas) and Rep. Chip Roy (R-Texas) are carrying companion bills in both chambers that seek to put patients back in control of their care by empowering them to use tax-advantaged dollars to purchase services that are shoppable and portable. Dozens of Florida hospitals max out of ICU capacity amid surge in… COVID-19 surge pushes US toward deadly clif vWhat the people of Alberta have come to learn through their government-run health system is that government agencies are not as efficient or effective as the private sector. Furthermore, individuals who are in control of their health care decisions keep those organizations in the private sector accountable when they are both the customer and the payer. The U.S. needs to follow the example of Alberta and seek opportunities to make the delivery of health care more of a free-market environment.
Health care not key to health outcomes
Darrouzet, 7-7, 20, Michael Darrouzet is the CEO of the Texas Medical Association. Jennifer Hanscom is the executive director and CEO of the Washington State Medical Association. Philip Schuh is the executive vice president and CFO of the Medical Society of the State of New York. All are board members of The Physicians Foundation, STAT News, Health care reform: The ‘new normal’ needs to go beyond clinical care, https://www.statnews.com/2020/07/07/new-normal-health-care-go-beyond-clinical-care/
Over the past decade, state and federal governments, health insurance companies, health care delivery systems, and physicians have struggled over who should bear the cost when patients get sick. The Centers for Medicare and Medicaid Services and private insurance companies have increasingly shifted this risk to physicians, holding physicians responsible for patients’ health through quality measures and financial rewards and penalties The problem is that these measures, incentives, and risk models focus almost entirely on clinical care. Yet social and environmental factors, such as access to healthy food, safe housing, and other social determinants of health, drive 70% of health outcomes.
US has higher cancer life expectancy rates and health care is just one factor
Chris Jacobs, 2019, writer @ The Federalist, The Case Against Single Payer, Kindle Book
Single-payer supporters often claim that the United States’ poor life expectancy rate compared to other developed countries reflects a poor health system, making the argument for socialized medicine. However, many other factors also affect Americans’ health relative to other countries—for instance, our much more heterogeneous population and other countries found substantially higher colon cancer survival rates for American elderly seniors (those over age 75), in large part because screening did not decline with age in the United States.32 While other countries limit access to screening and treatment for older individuals in ways that raise death rates, the United States’ death rates decline relative to its peers as seniors age, precisely because American seniors maintain access to treatments. Single-payer supporters often claim that the United States’ poor life expectancy rate compared to other developed countries reflects a poor health system, making the argument for socialized medicine. However, many other factors also affect Americans’ health relative to other countries—for instance, our much more heterogeneous population when compared to smaller European nations. Moreover, Americans’ higher obesity rates appear to affect death and life expectancy rates, as do higher rates of violent deaths (both homicides and suicides).33 These issues may provide some commentary on American society, but they do not directly speak to the merits of America’s health-care system relative to its peers’. On that front, the United States has long boasted superior outcomes from cancer treatment—the leading cause of death in developed nations—than its European counterparts. For individuals diagnosed during the years 1995-1999, American patients had an average survival rate of 11.1 years, or nearly 16% greater than the 9.3 years faced by European patients.34 The survival gap between American and European patients has remained constant going back for more than a decade.35 Moreover, while Americans spend more on cancer treatment than Europeans, they also receive more benefits, in the form of longer survival times. From 1983 through 1999, American patients received a net financial benefit—that is, increased survival compared to their European peers, even after accounting for higher spending levels—of $598 billion, or about $43 billion per year.36 Better access to treatment, better survival times, and more benefits to patients—the arguments for the American health system over single payer seem obvious, except to those on the left. Jacobs, Chris. The Case Against Single Payer . Republic Book Publishers. Kindle Edition.
Life expectancy isn’t largely determined by health care
Sally Pipes, 2020, False Promise: The Disastrous Reality of Medicare for All, Pipes is the President & CEO, Pacific Research Institute .
LIVING (AND DYING) IN AMERICA Similarly—and perhaps counterintuitively—life expectancy isn’t an accurate measure of the quality of a nation’s health care system. That’s largely because so many of the factors that influence life expectancy have nothing to do with health care. These are just the factors that drive down U.S. life expectancy. For example, the United States has a much higher homicide rate than other developed countries. In 2016, there were 5.3 murders per 100,000 people in the United States.34 That same year, the United Kingdom had just 1.2 murders per 100,000 people; Canada had about 1.7.35 Americans are also more likely to die in car accidents. According to the WHO, there were over 34,000 “road traffic deaths” in the United States in 2013, compared to just over 1,800 in the United Kingdom and over 2,100 in Canada.36 Per capita, the United States has nearly four times as many traffic deaths as the United Kingdom, and nearly twice as many as Canada. The suicide rate in the United States is higher than in Canada and almost double that in the United Kingdom.37 Then there is America’s epidemic of drug overdoses. According to the United Nations Office on Drugs and Crime, in 2015 the United States had around 246 drug-related deaths per 1 million people aged 15–64.38 Compare that to just under 105 per million in Canada in 2007, the most recent year for which data are available. The United Kingdom’s drug-related death rate was 67 per million people aged 15–64 in 2014—again, the most recent year for which data are available.39 Unfortunately, drug-related deaths have only grown more common in the United States. The death rate from drug overdoses increased between 2013 and 2017 in all but three states.40 These statistics are disheartening. And they have serious implications for public policy. But it’s hard to see how implementing single-payer health care in the United States would drive down the country’s rate of murders or traffic accidents. Even within the United States, health care doesn’t correlate all that much with life expectancy. A study in the Journal of the American Medical Association found that life expectancy varies from 66 to 87 years in the United States, mostly because of behavioral and socioeconomic factors. Only 27 percent of the difference can be attributed to health care.41 Economists Robert L. Ohsfeldt and John E. Schneider have calculated that the United States has a higher life expectancy than all other OECD countries after adjusting for fatal injuries.42 And what about the WHO’s all-encompassing health system rankings? The methodology leaves much to be desired. One-quarter of the ranking comes from life expectancy—a metric we now know to be flawed. Another 25 percent derives from “financial fairness.”43 In other words, the WHO prizes health care systems that treat patients the same over those that treat them well. As a result, the rankings aren’t just flawed—they’ve stacked the deck in favor of single-payer systems.
US health care better than other countries
Sally Pipes, 2020, False Promise: The Disastrous Reality of Medicare for All, Pipes is the President & CEO, Pacific Research Institute .
Focus on actual health outcomes, and it’s clear the United States outperforms most other countries, especially those with single-payer care. Americans are healthier because our health care system devotes more resources to the best treatments, technology, and physicians. The United States may spend more on health care than other countries, but Americans are getting the most bang for their buck. This shouldn’t come as a surprise. Markets are the most efficient way to allocate scarce resources.
Rising demand for care will outpace supply
Chris Jacobs, 2019, writer @ The Federalist, The Case Against Single Payer, Kindle Book
Obviously, this analogy has its limits. Few rational individuals would subject themselves to invasive, and potentially painful or dangerous, medical procedures just to “get their money’s worth” out of the health-care system. But making health care so easy to access would encourage additional spending. In fact, as we shall soon see, two analyses of single-payer health plans assumed that demand for health care would rise so quickly that the available supply could not meet it.
Single Payer – if it reduces costs – does so by taking money away from the medical system – increased coverage will reduce actual access to care
Book, Heritage Foundation Senior Research Fellow specializing in Health Economics 2009, (Robert A, “Single Payer: Why Government-Run Health Care Will Harm Both Patients and Doctors”, April 3, 2009, available at https://www.heritage.org/health-care-reform/report/single-payer-why-government-run-health-care-will-harm-both-patients-and accessed 8/19/17)
What many fail to appreciate, however, is the extent to which the existence of multiple, competing payers prevents government payers such as Medicare from reducing their payment levels to much lower levels than prevail now. As it stands, a reduction in Medicare payment rates can induce physicians to drop Medicare patients and try to make their living from a higher percentage of (or even only) privately insured patients. This would inevitably result in reduced access to care for Medicare patients-and thus political pressure from those patients for increased Medicare payments to improve access. The Medicare Model If Medicare or something like it were the “single payer”-the sole purchaser of health care-no such pressure would exist. If the single payer established lower payment rates, by definition physicians could not drop out and make their living from other patients, because there wouldn’t be any other patients.[3] The only alternative for a physician would be to cease the practice of medicine and either retire or find another profession. While this would certainly happen to some degree, a large percentage of physicians-who have invested many dollars and years of training in their practices-would be unable to find an alternative profession that is nearly as satisfying or as remunerative. The inevitable result would be much lower payment rates and lower income for physicians.[4] Patients would suffer as well, especially in the long run. Because fewer highly talented people would be willing to undergo the years of training (under difficult working conditions and low pay) to become physicians, patients would suffer decreased access to health care and longer wait times. Lower payments would mean that physicians would invest less in advanced medical equipment and would likely spend less time with each patient. In addition, with fewer people undergoing the training necessary to conduct medical research, new treatments and cures would be developed at a slower rate, costing many lives. Medicare Payment Levels Medicare determines the level of its payments to physicians based on a complex formula involving crude estimates of the relative costs of providing different services,[5] annual adjustments based on estimates of demand for services, and growth in the Medicare population and the overall economy. The annual adjustment process is expressed in the “Sustainable Growth Rate” (SGR) rule[6] which attempts to constrain the growth in Medicare spending and “make up” for the differences between previous years’ estimated and actual utilization. Each year since 1999, the SGR calculation has called for a reduction in the Medicare payment levels (a “negative update”) for physician services, because actual use outstripped previous forecasts, and forecasted future utilization outstripped the growth rate of the Medicare population and gross domestic product (GDP). And each year, physicians’ representatives have gone to Congress to argue that reducing payments will cause some physicians to drop out of the Medicare program, reducing elderly Americans’ access to health care. Negative updates were allowed to go into effect in only three of the last 11 years-in the other eight years, after intensive lobbying from physician groups, Congress has intervened and passed legislation either freezing payments or providing a positive update.[7] Competition Among Buyers The basis for the physicians’ now-annual argument to Congress is that reducing Medicare payments will cause more physicians to drop Medicare patients and make their living from privately insured and self-paying patients only. Indeed, anecdotal evidence indicates that some physicians have already done so,[8] as Medicare payments are already significantly below those of private insurance by almost 20 percent for physician services overall and by 12 percent for primary care.[9] As if to demonstrate the effects of lower payments, in most states Medicaid payments are even lower than Medicare’s, and far fewer physicians participate in Medicaid. Not surprisingly, states with relatively lower Medicaid payments compared to other states have lower rates of physician participation in Medicaid.[10] Access Issues Physician advocacy groups make the reasonable-and believable-argument that every reduction in the Medicare payment rates will result in a further reduction in the number of physicians who find it worthwhile to take Medicare patients and instead try to make their living from patients with private payers. A survey found that in response to a proposed 10 percent cut in Medicare rates, 28 percent of physicians would stop accepting new Medicare patients, 8 percent would stop treating Medicare patients already under their care, and much higher percentages would discontinue nursing home visits, reduce available hours, or defer investment in medical and health IT equipment.[11] Obviously, this would not affect physicians in all specialties equally. Most pediatricians have very few if any Medicare patients[12] and would hardly be affected at all, but cardiologists and oncologists, for example, would be hit hard, since a large percentage of their potential patients are over age 65. The impact on nephrologists would be especially severe, because anyone with end-state renal disease is covered by Medicare regardless of age. Yet for every reduction in the payment level, a few more physicians would find it better to drop Medicare than to stay in. The absence of other payers would give the “single payer” the freedom to reduce payments far more than Medicare can in the presence of a large percentage of privately insured patients. The result would be substantially lower payments-the “single payer” would be a “stingy payer.” Physicians’ income would be substantially reduced. Indeed, in countries with single-payer health systems, the average income of physicians is substantially lower than in the United States. For example, physicians in the Britain and Canada have incomes more than 30 percent lower than their U.S. counterparts.[13] The existence of multiple private payers limits not only the ability of Medicare but also that of private payers themselves to reduce payment levels. Although physicians usually face “take it or leave it” contracts from insurance companies, and most physicians have little ability to actually negotiate, a health plan that sets payment rates too low will find that many physicians choose to “leave it.” When enough physicians leave, patients have difficulty obtaining access to care and eventually leave the health plan. In order to continue to sell the health plan (either to individuals or to employers), the insurance company will have to increase payments to induce physicians to join. While this process is slow and imperfect compared to market mechanisms in other industries, it does limit the ability of plans to set arbitrarily low payment rates.[14] “Stingy Payer” Damages Future Generations as Well The establishment of a “single payer” health care system would inevitably result in lower payments for physician and other health care providers. The immediate effect of having a single (“stingy”) payer would be lower incomes for physicians and a reduction in the supply of active physicians, thereby impairing access to health care for all patients. However, the result of “single/stingy payer” health care will not only be lower incomes for physicians now but reduced access and lower quality health care for future generations as well.
Single Payer Cost savings come from cutting medicine
Klein, Vox health care editor 2016, (Ezra, “Bernie Sanders’s single-payer plan isn’t a plan at all” Jan. 17, 2016, available at https://www.vox.com/2016/1/17/10784528/bernie-sanders-single-payer-health-care accessed 8/19/17 TOG, * WAVE ONE*)
Sanders calls his plan “Medicare for all.” But it actually has nothing to do with Medicare. He’s not simplysimply expanding Medicare coverage to the broader population — he makes that clear when he says his plan means “no more copays, no more deductibles”; Medicare includes copays and deductibles. The list of what Sanders’s plan would cover far exceeds what Medicare offers, suggesting, more or less, that pretty much everything will be covered, under all circumstances. Bernie’s plan will cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments. Patients will be able to choose a health care provider without worrying about whether that provider is in-network and will be able to get the care they need without having to read any fine print or trying to figure out how they can afford the out-of-pocket costs. Sanders goes on to say that his plan means “no more fighting with insurance companies when they fail to pay for charges.” To be generous, it’s possible that Sanders is just being cynical in his wording, and what he means is that under his plan, individuals have to fight with the government rather than private insurers when their claims are denied. But the implication to most people, I think, is that claim denials will be a thing of the past — a statement that belies the fights patients have every day with public insurers like Medicare and Medicaid, to say nothing of the fights that go on in the Canadian, German, or British health care systems. What makes that so irresponsible is that it stands in flagrant contradiction to the way single-payer plans actually work — and the way Sanders’s plan will have to work if its numbers are going to add up. Behind Sanders’s calculations, for both how much his plan will cost and how much Americans will benefit, lurk extremely optimistic promises about how much money single-payer will save. And those promises can only come true if the government starts saying no quite a lot — in ways that will make people very, very angry. What Sanders doesn’t tell us that we really need to know “They assumed $10 trillion in health care savings over 10 years,” says Larry Levitt, vice president at the Kaiser Family Foundation. “That’s tremendously aggressive cost containment, even after you take the administrative savings into account.” The real way single-payer systems save money isn’t through cutting administrative costs. It’s through cutting reimbursements to doctors, hospitals, drug companies, and device companies. And Sanders gestures toward this truth in his plan, saying that “the government will finally have the ability to stand up to drug companies and negotiate fair prices for the American people collectively.” But to get those savings, the government needs to be willing to say no when doctors, hospitals, drug companies, and device companies refuse to meet their prices, and that means the government needs to be willing to say no to people who want those treatments. If the government can’t do that — if Sanders is going to stick to the spirit of “no more fighting with insurance companies when they fail to pay for charges” — then it won’t be able to control costs. The issue of how often the government says no leads to all sorts of other key questions — questions Sanders is silent on. For instance, who decides when the government says no? Will there be a cost-effectiveness council, like Britain’s National Institute for Health and Care Excellence? Or will the government basically have to cover every treatment that can be proven beneficial, as is true for Medicare now? What will the appeals process be like? This might sound technical, but it’s absolutely critical. Sanders implies everything will be covered because he knows how important that question is to people. But everything won’t be covered. So who decides, how do they decide, what gets covered, and what doesn’t? Without knowing that, it’s impossible to say whether a particular single-payer system is a good idea or a really, really bad one. Another crucial question is whether Sanders envisions the possibility of exit inside his system. Technically, a single-payer system is a system with, well, a single payer. Private insurers are outlawed — otherwise, it would be a multi-payer system. But the term is often used more loosely than that, and many systems that get mentioned during discussions of single-payer, like the French system, include various kinds of supplementary, private insurance that people generally purchase. The role of private insurers matters because it drives the government’s bargaining power. If drug companies either sell to the government or they go out of business, then the government can get better prices. The problem there is obvious, though: What do people do if the government doesn’t cover a treatment they need? But if there are private insurers selling add-on policies to wealthier Americans, then drug companies can deal only with them, and the government’s negotiating power wanes. Another question Sanders’s plan doesn’t answer but is crucially important: How do you guarantee physical access to medical care? Right now hospitals charge Medicaid one price, Medicare a somewhat higher price, and private insurers an even higher price. If the entire system is squeezed down to Medicare pricing, a lot of hospitals are going to close. How will Sanders keep that from happening? Or will he let it happen, even if it means people in rural areas need to drive hours for care?
Absent Primary Care expansion – plan will fail in improving health outcomes
Heintzman et. al. 2014 (John Heintzman, assistant professor Oregon Health and Science University, Department of Family Medicine, Rachel Gold, investigator Kaiser Center for Health Research, Steffani R Bailey, assistant research professor, and Jennifer E DeVoe, chief research officer OHICN, “The Oregon experiment re-examined: the need to bolster primary care.” The BMJ 349 (2014),
In a qualitative analysis of a representative sample of new Medicaid enrollees in the Oregon experiment, interviewees described the need for continuity in their relationship with a primary care provider who could work with them over months—or years—to catch up on previously delayed healthcare needs and help coordinate necessary care.16 Baicker and colleagues’ finding that patients who gained Medicaid coverage reported few health improvements in the short term could be because they lacked access to primary care, because the follow-up period was too short to see the benefits of partnering with a primary care provider, or both. Indeed, many patients in Baicker et al’s study lost their new Medicaid coverage within six months,15 giving them little time to establish such partnerships and work towards achieving long term health gains. Another study, however, showed that when patients retain coverage they eventually use primary care services at rates similar to other insured patients.17 This study, by Gold and colleagues, used electronic health record data from 67 federally qualified health centers in Oregon to study how patients used primary care medical services one year before and one year after gaining Medicaid. Gold and colleagues found a sharp increase in the use of primary care services by newly insured patients immediately after coverage began. This suggested pent-up demand for primary care among uninsured patients. However, within three months the level of use among newly insured patients fell to the level of other insured patients. Those who remained uninsured throughout the study period continued to receive fewer primary care services than those with coverage.17 This study also showed that patients who were registered with a federally qualified health center before getting Medicaid coverage sought more primary care services from this same health center after they gained coverage. This suggests that for those with existing access to a primary care clinician, gaining public insurance coverage facilitates the utilization of primary care, and it does so in a pattern equivalent to other insurance types with similar primary care access. The association between new Medicaid coverage and increased use of emergency departments reported by Taubman and colleagues14 was likely mitigated (or not significant) for those receiving good primary care services—it has been demonstrated in many settings that adequate availability of primary care reduces visits to the emergency department and hospital admissions and that insurance coverage and primary care availability are interdependent in improving outcomes and providing services.18 19 20 21 22 23 24 Indeed, a recent editorial in The BMJ highlighted that in Massachusetts insurance expansion alone did not reduce hospital readmissions,25 possibly because it was not accompanied by expanded access to primary care. In summary it is unwise to analyse coverage expansion without considering (and, ideally, controlling for) how access to, and quality of, primary care affects study outcomes. The importance of a high quality primary care infrastructure, coupled with adequate insurance coverage, cannot be overstated. Oregon has made significant progress since the 2008 expansions: the introduction of coordinated care organizations and a renewed focus on population health, primary care, and Medicaid payment changes are associated with significant reductions in emergency department visits and hospital admissions and greater use of primary care.26 Where do we go from here? International evidence indicates that a robust primary care infrastructure must accompany coverage expansions in order to maximize individual and population health gains.18 19 Yet the US faces a critical shortage of primary care clinicians, which is associated with overuse of emergency departments, hospitals, and other high cost resources.20 27 28 As millions of American people obtain new coverage, primary care shortages may grow more painful—a system unable to meet current demand will struggle even more as that demand rapidly expands. Thus achieving the US Institute for Healthcare Improvement’s triple aims of improving population health, improving the experience of care, and lowering the cost of care29 requires people to have both insurance coverage and adequate primary care. The Affordable Care Act will help people obtain insurance, but where will they go for primary care? We suggest several measures. Education of medical graduates (largely funded by US taxpayers) must be matched to the population’s healthcare needs. This will require the creation of new systems to regularly assess needs, prioritize resources, and develop new support programs to train the necessary primary care workforce. The accountability of this workforce to society has been emphasized recently in a report from the Institute of Medicine of the National Academies, which called for greater transparency in the US graduate medical education system.30 Alternative payment structures must also be developed to better support and incentivize primary care clinicians and patient centered medical homes to meet the needs of newly insured patients. Current pilot programs should be rigorously evaluated and replicated if they prove effective.31 32 Public healthcare dollars should be allocated based on the value of primary care. Finally, new research methods are needed to study the process, outcomes, and complexity of primary care. The fields of complexity science, multilevel evaluation and intervention, dissemination and implementation, and others must help build understanding of how to most effectively deliver and evaluate primary care. Conclusion If primary care isn’t bolstered other efforts to improve the US healthcare system may fail. Health reform efforts that do not enhance primary care infrastructure can only tackle part of the population’s true needs. Oregon is now seeing early signs of success from combining insurance reform and expansions with the reorganization of primary care.26 We hope that these early signs and the lesson that primary care infrastructure is a necessary companion to insurance expansions—in the US and in any healthcare system—are not lost among the attention paid to more politically provocative research findings.
Can’t Solve — Demand for Doctors, especially with increased coverage, outstrips supply
IHS report for the Association of American Medical College, 2015, (“The Complexities of Physician Supply and Demand: Projections from 2013 to 2025,” prepared for the Association of American Medical Colleges by IHS Inc., Washington, DC: Association of American Medical Colleges, available at https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=AAMC-_-ScientificAffairs-_-PDF-_-ihsreport,
Study results suggest the demand for physician services is growing faster than supply. While growth in the supply of APRNs and other health occupations may help to alleviate projected shortfalls to an extent, even taking into consideration potential changes in staffing, the nation will likely face a growing shortage in many physician specialties—especially surgery-related specialties. A multi-pronged strategy will be needed to help ensure that patients have access to high-quality care.
All supply and demand projections are reported as full time equivalent (FTE) physicians, where an FTE is defined for each specialty as the average weekly patient care hours for that specialty. 2 Key findings include:
- Demand for physicians continues to grow faster than supply, leading to a projected shortfall of between 46,100 and 90,400 physicians by 2025. Although physician supply is projected to increase modestly between 2013 and 2025, demand will grow more steeply (Exhibit ES-1). Across scenarios modeled, total physician demand is projected to grow by 86,700 to 133,200 (11-17%), with population growth and aging accounting for 112,100 (14%) in growth. By comparison, physician supply will likely increase by 66,700 (9%) if labor force participation patterns remain unchanged, with a range of 33,700 to 94,600 (4-12%), reflecting uncertainty regarding future retirement and hours-worked patterns.
- Projected shortfalls in primary care will range between 12,500 and 31,100 physicians by 2025, while demand for non-primary care physicians will exceed supply by 28,200 to 63,700 physicians. The shortfall range reflects comparisons of all the supply scenarios to all the demand scenarios, and uses the 25th to 75th percentiles of projected shortages across the comparisons. These percentiles reflect that the extreme shortage/surplus projections are least likely to occur as the extreme shortage/surplus projections compare the highest/lowest demand projections to the lowest/highest supply projections.
- Expanded medical coverage achieved under ACA once fully implemented will likely increase demand by about 16,000 to 17,000 physicians (2.0%) over the increased demand resulting from changing demographics. The Congressional Budget Office estimates that 26 million people who otherwise would be uninsured in the absence of ACA eventually will have medical insurance. Taking into consideration the health and risk factors of the population likely to gain insurance and estimated changes in care utilization patterns associated with gaining medical insurance, the projected increase in demand for physician services is about 2.0%. The increase is highest (in percentage terms) for surgical specialties (3.2%), followed by primary care (2.0%), medical specialties (1.7%), and “all other” specialties (1.5%). Within these broad categories there are differences in the impact of ACA for individual specialties.
- The lower ranges of the projected shortfalls reflect the rapid growth in supply of advanced practice clinicians and the increased role these clinicians are playing in patient care delivery; even in these scenarios, physician shortages are projected to persist. New payment methodologies, including bundled payments and risk-sharing arrangements, and innovations in technology, suggest that the work of health professionals may be restructured in the coming years. Given the number of nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists graduating each year, if labor force participation patterns remain unchanged then the supply of advanced practice nurses (APRNs) will grow more rapidly than is needed to keep pace with growth in demand for services at current APRN staffing levels. These trends suggest that an additional 114,900 APRNs could be available to absorb into the health care system to both expand the level of care currently provided to patients and help offset shortages of physicians. Similarly, the supply of physician assistants (PAs) is projected to increase substantially between 2013 and 2025, though additional research is needed to quantify the expected impact. While this rapid growth in supply of APRNs and PAs could help reduce the projected magnitude of the physician shortage, the extent to which some specialties (e.g., surgery specialties) can continue to absorb more APRNs and PAs given limited physician supply growth is unclear.
- Due to new data and the dynamic nature of projected assumptions, the projected shortfalls of physicians in 2025 are smaller than shortfalls projected in the earlier study. We project that demand for physicians in 2025 will exceed supply by 46,100 to 90,400. This compares with a 130,600 shortfall projected in the 2010 study. Current projections suggest primary care physician demand in 2025 will exceed supply by 12,500 to 31,100 physicians (the 2010 study projected a 65,800 shortfall, about half the overall shortage). The projected shortfall for non-primary care is 28,200 to 63,700 (versus a projected shortfall of 64,800 in the 2010 study). Factors explaining differences between the 2015 and 2010 projections include:
- The U.S. Census Bureau revised downward its 2025 population projections by about 10.2 million people (from 357.5 million to 347.3 million). This downward revision equates to approximately 24,000 lower FTE demand for physicians.
- The number of physicians completing their graduate medical education has risen from about 27,000 to about 29,000 annually.
- The new projections more closely reflect implementation of ACA, growth in supply of advanced practice clinicians, and trends in use of health care services.
- The 2010 study assumed that supply and demand were in equilibrium in 2008 for all specialties except primary care, whereas this update assumes supply and demand were in equilibrium in 2013 for all specialties except primary care and psychiatry. Hence, the new demand projections extrapolate a “2013” level of care delivery compared with the “2008” level of care delivery extrapolated by the earlier 2010 projections.
Oregon experiment shows that increased coverage did not improve health outcomes despite increasing costs by 35% – no measurable improvement in physical health
Baicker et al, professor of health economics in the Department of Health Policy and Management at the Harvard School of Public Health, 2013 (Katherine Baicker, Sarah L. Taubman, Heidi L. Allen, Mira Bernstein, Jonathan H. Gruber, Joseph P. Newhouse, Eric C. Schneider, Bill J. Wright, Alan M. Zaslavsky, and Amy N. Finkelstein. “The Oregon experiment—effects of Medicaid on clinical outcomes.” New England Journal of Medicine 368, no. 18 (2013): 1713-1722 available at https://www.nejm.org/doi/full/10.1056/NEJMsa1212321#t=article accessed 5/24/17
Mean Values and Absolute Change in Health Care Utilization and Spending, Preventive Care, Access to and Quality of Care, and Smoking and Obesity with Medicaid Coverage. shows the effects of Medicaid coverage on health care utilization, spending on health care, preventive care, access to and quality of care, smoking status, and obesity. Medicaid coverage resulted in an increase in the number of prescription drugs received and office visits made in the previous year; we did not find significant changes in visits to the emergency department or hospital admissions. We estimated that Medicaid coverage increased annual medical spending (based on measured use of prescription drugs, office visits, visits to the emergency department, and hospital admissions) by $1,172, or about 35% relative to the spending in the control group. Medicaid coverage also led to increases in some preventive care and screening services, including cholesterol screening (an increase of 14.57 percentage points; 95% CI, 7.09 to 22.04; P<0.001) and improved perceived access to care, including a usual place of care (an increase of 23.75 percentage points; 95% CI, 15.44 to 32.06; P<0.001). We found no significant effect of Medicaid coverage on the probability that a person was a smoker or obese.
DISCUSSION
This study was based on more than 12,000 in-person interviews conducted approximately 2 years after a lottery that randomly assigned access to Medicaid for low-income, able-bodied, uninsured adults — a group that comprises the majority of persons who are newly eligible for Medicaid under the 2014 expansion.12 The results confirm that Medicaid coverage increased overall health care utilization, improved self-reported health, and reduced financial strain; these findings are consistent with previously published results based on mail surveys conducted approximately 1 year after the lottery.4 With these new data, we found that increased health care utilization observed at 1 year persisted, and we present new results on the effects of Medicaid coverage on objectively measured physical health, depression, condition-specific treatments, and other outcomes of interest.
Medicaid coverage had no significant effect on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. It increased the probability of a diagnosis of diabetes and the use of medication for diabetes, but it had no significant effect on the prevalence of measured glycated hemoglobin levels of 6.5% or higher. Medicaid coverage led to a substantial reduction in the risk of a positive screening result for depression. This pattern of findings with respect to clinically measured health — an improvement in mental health but not in physical health (Table 2) — was mirrored in the self-reported health measures, with improvements concentrated in mental rather than physical health (Table 3). The improvements appear to be specific to depression and mental health measures; Medicaid coverage did not appear to lead to an increase in self-reported happiness, which is arguably a more general measure of overall subjective well-being.
Hypertension, high cholesterol levels, diabetes, and depression are only a subgroup of the set of health outcomes potentially affected by Medicaid coverage. We chose these conditions because they are important contributors to morbidity and mortality, feasible to measure, prevalent in the low-income population in our study, and plausibly modifiable by effective treatment within a 2-year time frame.13-16 Nonetheless, our power to detect changes in health was limited by the relatively small numbers of patients with these conditions; indeed, the only condition in which we detected improvements was depression, which was by far the most prevalent of the four conditions examined. The 95% confidence intervals for many of the estimates of effects on individual physical health measures were wide enough to include changes that would be considered clinically significant — such as a 7.16-percentage-point reduction in the prevalence of hypertension. Moreover, although we did not find a significant change in glycated hemoglobin levels, the point estimate of the decrease we observed is consistent with that which would be expected on the basis of our estimated increase in the use of medication for diabetes. The clinical-trial literature indicates that the use of oral medication for diabetes reduces the glycated hemoglobin level by an average of 1 percentage point within as short a time as 6 months.15 This estimate from the clinical literature suggests that the 5.4-percentage-point increase in the use of medication for diabetes in our cohort would decrease the average glycated hemoglobin level in the study population by 0.05 percentage points, which is well within our 95% confidence interval. Beyond issues of power, the effects of Medicaid coverage may be limited by the multiple sources of slippage in the connection between insurance coverage and observable improvements in our health metrics; these potential sources of slippage include access to care, diagnosis of underlying conditions, prescription of appropriate medications, compliance with recommendations, and effectiveness of treatment in improving health.17
Anticipating limitations in statistical power, we prespecified analyses of subgroups in which effects might be stronger, including the near-elderly and persons who reported having received a diagnosis of diabetes, hypertension, a high cholesterol level, a heart attack, or congestive heart failure before the lottery. We did not find significant changes in any of these subgroups. To try to improve statistical power, we used the Framingham risk score as a summary measure. This allowed us to reject a decrease of more than 20% in the predicted 10-year cardiovascular risk or a decrease of more than 10% in predicted risk among the participants with high-risk diagnoses before the lottery. Our results were thus consistent with at best limited improvements in these particular dimensions of physical health over this time period, in contrast with the substantial improvement in mental health.
Turn: Studies Show Payment cuts lead to increased deaths
Wu, Ph.D., M.S., assistant professor, Sol Price School of Public Policy, University of Southern California, and Shen, assistant professor Graduate School of Business and Public Policy, Naval Postgraduate School 2014 [Vivian Y Wu and Yu-Chu Shen. “Long-Term Impact of Medicare Payment Reductions on Patient Outcomes.” Health Services Research 49.5 (2014): 1596–1615. PMC. Web. 20 Aug. 2017 https://doi.org/10.1111/1475-6773.12185, TOG, * WAVE ONE*]
Health policy researchers and decision makers have long been concerned about the relationship between provider payment generosity and quality of care for many reasons. One view about Medicare spending suggests that there is much inefficiency in the system so that it might be safe to reduce provider payments without hurting quality. Studies by leading researchers have demonstrated that Medicare often operates beyond the “flat of the curve,” where areas with additional care/spending are not associated with better outcomes (Fisher et al. 2003a,b; Baicker and Chandra 2004; Skinner, Staiger, and Fisher 2006). By contrast, several recent studies indicate that higher spending may be valuable, especially in the hospital setting. Greater hospital inpatient spending is shown to be associated with lower mortality rates in teaching hospitals (Ong et al. 2009), in selected states such as California (Romley, Jena, and Goldman 2011), Florida (Doyle 2011; Doyle et al. 2014), and Pennsylvania (Barnato et al. 2010); for a set of nationally representative hospitals (Romley et al. 2013) or for several medical (Kaestner and Silber 2010) or surgical (Chandra and Staiger 2007; Silber et al. 2010) conditions.
This important topic has sparked a long stream of research examining the effect of payment reductions on patient outcomes in the past. The literature points to a general finding that past payment reductions have led to cost-cutting responses in the management and provision of care (Feder, Hadley, and Zuckerman 1987; Newhouse and Byrne 1988; Hodgkin and McGuire 1994; Cutler 1995; Bazzoli et al. 2005, 2007, 2008; Lindrooth, Clement, and Bazzoli 2007; Zhao et al. 2008); and while more patients were being discharged in unstable condition (Kosecoff et al. 1990), there was limited or no adverse impact on patient outcomes (Kahn et al. 1990a,b; Rogers et al. 1990; Staiger and Gaumer unpublished data; Cutler 1995; Shen 2003; Volpp et al. 2005; Seshamani, Schwartz, and Volpp 2006; Seshamani, Zhu, and Volpp 2006). However, the literature has focused primarily on short-term impact. Our study fills the gap by examining the long-term effect of provider payment cuts by using a plausibly exogenous shock to hospital revenue—the Balanced Budget Act of 1997 (BBA). Understanding the long-term impact of the BBA on patient quality is especially timely in light of the recent Affordable Care Act (ACA) of 2010, which includes permanent Medicare payment cuts to providers that began in 2012.
Several facts highlight the importance of the BBA. First, the BBA contained the most significant Medicare payment reductions in decades. With the exception of the Prospective Payment System (PPS), the BBA is the only legislation that reduced Medicare inpatient payments in nominal terms, rather than just slowing down the growth rate. Second, BBA payment cuts could have a long-lasting effect on hospitals because the legislation not only reduced diagnosis-related group (DRG) payment levels between 1998 and 2002 but also permanently altered the formula for special add-on payments.1 As illustrated in Figure Figure1,1, even though hospital payments grew at the full “market basket” update after the 1998–2002 period, the gap in payment across hospitals was permanent (a more detailed explanation of Figure Figure11 is presented in the Results section). Third, Medicare BBA reductions occurred after a sustained period of declining inpatient admissions and lengths of stay, as well as aggressive payment negotiations from managed care plans (Wu 2009) that limited hospital ability to cost shift to private payers (Wu 2010). As a result, hospital actions to produce further savings in this environment were more likely to have direct consequences on patient outcomes than in previous decades.