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Expansion of Medicaid and the inevitable downgrading of doctors

Expansion of Medicaid and the inevitable downgrading of doctors

Perhaps the most important Obamacare lie among many will turn out to be the one that says that the Obamacare Medicaid expansion will lead to quality health care for the people newly covered by it.

Anyone who was even remotely familiar with the way Medicaid already worked was quite aware of this at the time Obamacare was passed.  Medicaid recipients were already having great difficulty getting a doctor to see them due to the low reimbursement rates.

The Obamacare Medicaid expansion provides people with the trappings of care but is unlikely to be able to deliver all that much of it—unless, of course, more doctors come under the thumb of government and are forced to accept Medicaid levels of reimbursement.

Oh well, doctors. They earn too much money anyway, don’t they?

Not in the Soviet Union they didn’t. Not even in post-Soviet Russia.  Here’s why [emphasis mine]:

Soviet doctors never had anything like the status and money of Western doctors. The medicine they practice was considered to be below the levels of the West, the system always suffered from shortages, and the social status of a provincial general practitioner was akin to a schoolteacher’s, respectable, but modest…

But under Communism, doctors at least lived no worse than anybody else — and maybe a bit better.

That has changed. Caught between an impoverished government that cannot afford universal medical care and a deep-rooted Soviet scorn for medicine-for-profit, many of Russia’s doctors, especially here in the provinces, seem worn thin, out of canteen water but still marching ahead.

When everything else took the capitalist road of development, and medicine was left on the socialist road, we got an imbalance that is killing medicine,” said Dr. Aleksei Golland, one of a handful of private doctors in Kostroma.

”It’s an economic death,” he said. ”If it continues like this, I see the murder of medicine in that the masses of quality doctors don’t have ground to stand on. A surgeon has to plant potatoes to feed his family.”

Ask what keeps the government-paid doctors going and the same words keep coming up: Vocation. Duty. Mercy. Naked enthusiasm…

A few doctors are doing pretty well. There are a handful of legally private doctors. And there are the doctors who practice a sort of black-market medicine in which they operate in state facilities, but charge their own little tolls.

Has the situation changed much in Russia since the above quotes from 2000? It certainly doesn’t seem that way. Perhaps that’s even part of the reason life expectancy there is so lousy.

Expect a war on doctors who don’t take Medicaid patients.  We already know what the result will be.

[Neo-neocon is a writer with degrees in law and family therapy, who blogs at neo-neocon.]


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So Obamacare promised cheaper, better healthcare/insurance for just about everyone.

And…a majority of the populace believed that you could get more, cheaper, and better all out of a government take over of an industry.

The NEA has certainly done a “good” job on the electorate.

I have Russian friends who came to America- one rich, the other middle class.

Rich; Father came to America for heart surgery.

Middle Class: Grandfather given pills, sent home to die w/out being told what was wrong with him.

PersonFromPorlock | December 5, 2013 at 11:57 am

Still, let’s not make plaster saints of doctors: they’ve done their part to make American healthcare expensive. The whole medical system is designed to keep market competition for patients from interfering with profits.

The ACA’s not the answer, but that doesn’t mean there isn’t a problem.

    I’m old enough to remember affordable health care. I went to see my doctor when I needed, then handed him (or on some days, a clerk/bookkeeper) a small payment, got a receipt, and left happy. If the service was covered by insurance, I went home and filled out paperwork to submit to my insurer and was reimbursed for the covered portion of what I’d paid.

    That was before Medicare and before the low and no co-pay mentality. My doctor didn’t have to have an administrative staff that was larger than his medical staff, one lady once or two days a week was it. The high cost of medical care is the result of big government and the entitlement mentality.

    Perhaps some physicians have added to the expense (in an age when prescription drugs are marketed to lengthen eyelashes, it almost has to be expected), but the market has to be there for them to prosper.

      PersonFromPorlock in reply to AZ_Langer. | December 5, 2013 at 5:09 pm

      True enough, and I apologize for accidentally downrating you. (Professor Jacobson, move the ‘reply’ button, please.)

      However, when profit is a percentage of costs, higher costs don’t get opposed all that fervently. I suspect a bit of that goes on in the healthcare business.

    thebigdogbarks in reply to PersonFromPorlock. | December 6, 2013 at 12:07 pm

    You’ve ignored basic economics!

    Think about the balance between supply and demand that results in the equilibrium or market price and the things that alter demand and supply. It’s not the doctors, it’s the government that created the problem by creating a vast array of direct and indirect subsidies that have increased demand (more and more consumers demanding more and more goods and services from doctors, hospitals, pharmaceutical companies, etc.). Employer sponsored insurance paid with pre-tax dollars, Medicare, Medicaid and now ObamaCare are all subsidies which drive up demand because consumers don’t directly see or feel the impact of the cost of medical care and thus have no restraint from demanding more and more even if the health benefits are minimal.

    Simultaneously, government also limits supply. A morass or state and federal regulations not only limits the supply of doctors, they also make it harder each year for doctors to practice independently from each other and from hospitals. This results in LESS competition and in some areas virtual monopolies in certain specialties. Government also prevents competition between hospitals by requiring a certificate of need (CON) for new hospitals and new equipment such as CT scanners, MRI, radiation therapy units, etc. This is done under the guise that fewer facilities and fewer machines will prevent “overuse” of medical services. What they are really saying is “we need to limit access because our subsidies have increased demand beyond the point of affordability”.

    ObamaCare increases subsidies and thus increases demand, but it aims to do this by subsidizing high volumes of low level care in order to “bribe” the maximum number of voters. ObamaCare means to subsidize lots of cheap stuff that many people use, i.e. birth control, annual physicals, etc., but it also aims to limit access to (by limiting payment for) treatments for more costly, but less frequent disorders such as cancer, heart disease, etc. That’s what the IPAB or “death panels” are for. As outlined by Obama’s architect for the ACA, Ezekial Emanuel, payments will be denied for treatment of certain conditions based on the cost of the treatment versus the value of the patient’s life (as determined by the government). Thus, an elderly patient with stage four colon cancer whose treatment is expensive and will only prolong life rather than cure him will likely not get treated. Similarly, a child with a disorder that is expensive to treat, but who likely won’y be a “productive” (as determined by the IPAB) citizen, won’t get treated either.

    The answer to this problem is not more government solutions. Government solutions have merely led to new problems for which the government proposes new solutions which, in turn, create further problems, and so on. The answer is to eliminate the government involvement an medicine and medical insurance and allow the free market to reset prices to the affordable levels we had before the government tried to solve non-existent problems (actually there was no problem. government – leftists – invented it to buy votes)

Those states that expanded Medicaid will be forced to require Doctors to treat Medicaid patients to keep their licenses.

It will have to happen that way.

    genes in reply to Musson. | December 5, 2013 at 6:14 pm

    They will simply require them to take patients referred by the hospital if they want to use the facilities.

    Fiftycaltx in reply to Musson. | December 5, 2013 at 6:19 pm

    Hey, just do what Rangel suggested and bring back the DRAFT! National security and all that. Then you can force docs to go where no doc has gone before, like southside Chicago or Bakersfield. Make them warrant officers and pay em’ $1000 a month and all the SOS they can eat. Then sentence them to debtors prison when they can’t pay back their $250000 student loans.

    What could go wrong?

A lot more work, a lot less pay. What could go wrong?

Bitterlyclinging | December 5, 2013 at 12:46 pm

There’s always the rifle butt or the barrel itself that could be of use to suplement the care of all those new enrollees. Former Obama Regulatory Czar Cass Sunstein was, after all, enamored with former Chinese Communist Party Chairman Mao tse Tung and especially with his quote “All power emanates from the barrel of a gun”
The quote could be quite useful in persuading those physicians who decide to opt out of Obamacare completely and pursue a career in some sort of cash only “Concierge medicine” to return to the exclusive service of their fellow man, irregardless of remuneration.
Failing that, Comrade Barack could always fall back on that pool of Mexican Carpenters he’s hell bent on bringing onto this side of the border. Since full time jobs are in short supply because of Obamacare and most of these newly created part time earners will never be able to afford the new homes this flood of newly arrived Mexican carpenters would be able to produce, Comrade Barack can simply declare, via Executive Order, these former Mexican carpenters are now qualified Mexican physicians capable of caring for all those new Obamacare enrollees.
Between Comrade Barack ion the US and Comrade Maduro in Venezuela the world could be treated to a spectacular demonstration of just how wonderfully creative Socialism is.

The Obamacare scheme is proceeding exactly according to plan, as designed by the folks who were ‘in the room’ when the bill was being written.

Let’s look at the AMA- regular doctors don’t belong to this organization for hundreds of reasons, they are NOT a voice for primary care providers. They earn most of their money by licensing the CPT code system to insurance companies and the government, to the tune of well over $70 million.

Soon, they’ll force doctors to bill and code with ICD-10, there are over 70,000 codes? for them to learn. Who’s surprised Obamacare will reward hospitals to buy up the few remaining private practices, pay docs a fixed (low) salary and send more patients to their bloated specialist network?

Some desperate states are allowing podiatrists to expand their scope of practice, they’re past the ankle, on the way to the knee and hip. A nurse can earn a phD and be called “Doctor Nurse” to give the illusion patients are getting more care than they actually are. Disgusted middle-aged doctors who could be mentoring the next generation are retiring, tired of living under threat of ruin by malpractice attorneys and insurance companies that want to kick them out of the network cause they’re ‘too expensive’.

Look, you can’t get more care (or quality or efficiency or good health) by establishing massive central bureaucracies in hospitals, states and in Washington. Every one of these agencies gets a cut of the healthcare dollar and in the end the patients and the doctors get less. Obamacare is right on schedule and citizens need to realize only a quick about-face will help them and their children.

    thebigdogbarks in reply to Chicklet. | December 6, 2013 at 12:14 pm

    The answer is NOT to have the government limit everybody else (specialists, non-physican practitioners, etc.) and leave primary care docs alone. That mentality of envy is what permitted the government to gain further control of medicine. The answer is to get the government out of medicine and medical insurance and allow the market to work. That means people can choose who they see (MD, DO, non-physician, specialist vs primary care) and determine what each provider’s services are truly worth.

I remember reading about doctors in Cuba… highly trained in medicine by the Soviet system but because of communist market controls could not earn a decent living. Many of the female doctors had seconds jobs as prostitutes to keep the bills paid.


Henry Hawkins | December 5, 2013 at 2:59 pm

One wonders what Dr. Welby would make of all this.

BannedbytheGuardian | December 5, 2013 at 5:43 pm

What is this fixation on Russia at LI ? I have been to a Sanitorium in Sochi run by the trade unions & errrhh it was very different . The philosophy was closer to Baden Baden ( without the nice things of course) . Rest Ye Worker in lots of mineral baths.

There are systems elsewhere that would be a closer fit socially . One big difference is that medical studies are often heavily subsidised by the nation & doctors spend some time in the public system before branching out to private .

Even in Britain there are private doctors dentists hospitals & clinics & health insurance to cover some costs.

The cost of medical education in the Us is high. I know of a Nobel prize winner ( real one ) whose prize was all used to put his son through med school. Docs need to pay off their student loans also & unlike lawyers get sued for mistakes.

The objective of the onerous 2,700 page Obamacare bills is akin to the objective of the Enabling Act of pre-war Germany: enable the facists to consolidate absolute power.