October 11, 2012
Suppose that Congress passed a law requiring all health plans to pay for an hour of free conversation every year between patients and doctors. The logical question would be: where are the doctors going to find all the additional hours to provide this service? The same question is relevant for the Affordable Care Act. It promises almost everyone in the country access to annual physicals, mammograms, Pap smears, prostate cancer (PSA) tests, colonoscopies and other services most are not now getting—with no deductible and no co-payment. Who is going to deliver these services?
There’s an even more important question: when millions of Americans line up for additional preventive care, how will this affect cost, quality and access to care? In a 2003 study researchers at Duke University Medical Center estimated that it would require 1,773 hours a year of the average doctor’s time—or 7.4 hours every working day—for the average doctor to counsel and facilitate patients for every procedure recommended by the US Preventive Services Task Force. And remember, every so often a screening test turns up something that requires more testing and more doctor time. The current supply of medical personnel cannot come anywhere close to providing what has been promised.
In addition, screening tests and similar services add to healthcare costs, rather than reduce them. And sick patients may be crowded out in the process. Patients in higher-paying plans seeking preventive services could displace the more urgent needs of sick patients in lower-paying plans. The most vulnerable patients will be the elderly and the disabled on Medicare, poor families on Medicaid, and newly insured enrollees in subsidized private plans sold in the health insurance exchanges.
A major increase in demand and no change in supply will cause increased waiting for care almost everywhere, and one place patients will turn is to concierge doctors. In return for an annual fee, patients receive increased access and additional services. Whereas a doctor in a regular practice typically has about 2,500 patients, however, a concierge practice usually has only about 500 patients. The more doctors that opt out of conventional care for concierge care, the greater the rationing problem becomes for everyone left behind. This could result in a two-tiered system in which those with more financial resources have concierge care, and everyone else is subjected to rationing by waiting.
For its part, the Obama administration is caught on the horns of a dilemma. While it wants to be seen as the champion of preventive care, a vast increase in this kind of coverage will increase healthcare costs and crowd out access to care for those who have more serious medical needs. Even before healthcare reform, the Association of American Medical Colleges was predicting a 21,000 primary care physician shortfall by 2015, while the Health Resources and Services Administration at HHS estimated a shortage of between 55,000 and 150,000 physicians by 2020.
The Obama administration knows the problem and is quite worried about it. Is there anything it can do to ameliorate the situation?
Apparently, Health and Human Services Secretary Kathleen Sebelius plans to use $250 million targeted for “prevention and public health” in the Patient Protection and Affordable Care Act for physician training instead. The funds would train 500 physicians, 600 physician assistants, and 600 nurse practitioners. Also, she plans to raid pots of “stimulus” money created under the American Recovery and Reinvestment Act to subsidize the training of doctors and nurses. All told, the administration now claims it will train 16,000 primary care providers by 2015.
However, this initiative will not create any new medical residency slots, which are required before a medical graduate can practice medicine. Thus, it is unlikely that any additional physicians will be trained. Moreover, virtually all of the medical students and nursing students who will be subsidized are already enrolled in medical training programs.
The Affordable Care Act is bad medicine for the ailments of American healthcare. For a better approach, please consult my Independent Institute book, Priceless: Curing the Healthcare Crisis.
 Timothy Jost, “Implementing Health Reform: Preventive Services,” Health Affairs Blog, July 15, 2010.
 Damon Adams, “Who Has 7-Plus Hours a Day to Put Toward Preventive Care?” American Medical News, April 21, 2003.
 Louise B. Russell, “Preventing Chronic Disease: An Important Investment, but Don’t Count on Cost Savings,” HealthAffairs28 (2009): 42–45. doi: 10.1377/hlthaff.28.1.42.
 John C. Goodman, “For the Vulnerable, Expect Less Access to Care,” John Goodman’s Health Policy Blog, November 16, 2011.
 Devon M. Herrick, “Concierge Medicine: Convenient and Affordable Care,” National Center for Policy Analysis, Brief Analysis No. 687, January 19, 2010.
 Julian Pecquet, “Investment in Healthcare Workforce Announced as Doctor Shortage Looms,” Healthwatch, The Hill’s Healthcare Blog, June 16, 2010.
 Doug Trapp, “Primary Care Gets Boost with $250 Million in HHS Grants,” American Medical News, July 1, 2010.
 “Fact Sheet: Creating Jobs and Increasing the Number of Primary Care Providers,” Health Reform.Gov, December 12, 2010.
[Cross-posted in Psychology Today]
Read all posts by John C. Goodman