Will health care reform cause physicians to flee?

A physician friend asked me today if I had seen the survey in the New England Journal of Medicine that says nearly half of us will quit medicine if health care reform passes.   My fried, a life-long Republican, found the numbers difficult to believe.  So did I.

The New England Journal of Medicine (NEJM), one of medicine's most respected journals,  did not publish such a poll.  Apparently, in an earlier version of a web-based story posted on their jobs page, they reported the results of a poll conducted by a physician recruitment firm.   Partisan bloggers and networks jumped on the story as an argument against health care reform.

The Journal changed it's website to reflect explicitly the fact that the survey was industry-produced content in an advertising newsletter, not actual journal content.  I find the behavior of the Journal a bit problematic.  It looks bad when you have to clarify the origin and purpose of your content.  But this was clearly never a peer-reviewed journal article.

The Medicus Firm, a physician recruitment company, conducted an unscientific poll of some physicians regarding health care reform.  The announcement was entitled, "Health Reform May Lead to Significant Reduction in Physician Workforce".  The quote from their website says that:

About 25 percent of respondents were primary care physicians (defined as internal medicine and family medicine in this case), and of those, 46 percent indicated that they would leave medicine -- or try to leave medicine -- as a result of health reform.

This is a rather bold conclusion, especially given the data they report.   The physicians surveyed were from Medicus's own database; they were not a random sample from a national database.  And here were some of the actual questions and answers:

How do you think health reform WITHOUT the public option would affect the following?

Your Quality of Practice: 45.7% = No Impact/Remain Same

Your Career Satisfaction: 40% = No Impact / Remain Same

Your Income and Practice Revenue: 37% = No Impact/Remain the Same; 43% = Decline/Worsen Somewhat

Physician Supply in General: 52% = Decline/Worsen Somewhat

Quality of Medical Care in General: 49% = Decline/Worsen Somewhat

In other words, when asked about HCR without a public option (there is no public option in the current legislation), a plurality felt that their own quality of practice and career satisfaction would be unchanged; many thought that their income would drop; many thought medical care would decline, and many thought that physician supply would decline.  Many physicians can form reasonable opinions about most of those measures---but not physician supply.  Nothing I do in my daily practice give me data on physician supply. 

When asked, "How do you think the passage of health reform WITHOUT a public option would affect your professional/practice plans, if at all?" 70% of respondents said, "no change."  It is not reported in this data, but apparently primary care physicians, who made up about a third of respondents, were more likely to say that they would leave medical practice. 

I have no doubt that there are unsatisfied physicians out there.  This data, gathered unscientifically, hyped by the survey company, and widely picked up by partisan media, is not a reliable measure of doctors' responses to health care reform.
Thinking about it from a purely practical standpoint, how many primary care physicians can financially afford to retire?  How many can simply pick up and change careers?

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Thinking about it from a purely practical standpoint, how many primary care physicians can financially afford to retire? How many can simply pick up and change careers?

Hey, maybe they'll pack up and go to some country where the Government keeps its hands off of health care. Saudi Arabia, maybe, or Uganda.

By D. C. Sessions (not verified) on 18 Mar 2010 #permalink

Well, I do not know if half will leave or not. I do know that there will be some doctors that will hang up their white coats and close their doors becuase of this insanity. I live in a small town where we only have four doctors to go to. Two of them has vowed to seek a new profession if they are payed one penney less due to this bill. That's half in my town. We cannot afford to loose more doctors and nurses.

If I had a child who was considered a career in the medical profession right now, I would do my best to talk him/her out of it. The government sure as hell isn;t going to give the doctors what they deserve and a doctor working forhimself cannot make it on his own very well these days unless he chooses not to pay malpractice insurance. He would be better off going to a free country like Mexico to practive medicine after this bill passes. Rest assured Big Pharma and the lawyers and the union thugs and the politicians will not be affected. Just the innocent people.

KILL THE BILL! Free America from this socialist takeover!

American refuses Universal (socialist) HELLthcare!

By Health Bill Slayer (not verified) on 18 Mar 2010 #permalink

I can understand that some older MDs with a well-filled pension fund may chose to retire early, should their income become somewhat less. But for the rest of them, what would they do? Become bankers? (Certainly pays better, but currently not so popular). Engineers? (Pays, at best, 1/3 of what a regular MD gets). Bio-scientists? (at postdoc pay?).
And if it is really so bad, why is it so difficult to get into medical school?

Two of them has vowed to seek a new profession if they are payed one penney less due to this bill.

1 they are lying

2 please hold them to it when HCR passes

By bikemonkey (not verified) on 18 Mar 2010 #permalink

On the other hand, Health Bill Slayer (a pseudonym that makes your agenda clear as crystal), my doctor did "hang up his white coat" after years of beating his head against the totally-for-profit HMOs; having bean-counters with no medical training second-guessing his treatment of his patients (can you say, "practicing medicine without a license"?) just flat wore him down. The doctor who replaced him told me that, if her daughter were contemplating going into medicine, she would strongly advise her against it, and for similar reasons.

It's 'claim they will quit' versus 'actually did quit'.

I doubt if they are lying. I hope HELLthcare "reform" never passes. I hope if it does pass, there will be so many lawsuits that it will die in the courts. Besides, I'll be moving to one of the smart states who chose to exercise the 10th amendment on this. The states that will be standing when other socialist states are in a situation ... well ... like California - broke, rotton, sodomites galore, socialist marxist abundant, and no end in sight. So ask yourself. Do you really wnat to make the rest of the nation as miserable and hellbound as California. If so, vote for this bill. If you wish to remain soverign, independent, free, and normal, KILL THIS BILL.

By the way if this assfaced bill passes, my paycheck better the hell not decrease by one penney. I will be lividly pissed to the point I might be praying for an asteroid to hit the son of bitch that thought this garbage up. I just ask for a small asteroid - about 25 yards in diameter. Yes I still use YARDS. Excuse me for being an American. I also still use BC and AD, inches, miles, feet, yards, and whatever else I have used all my life.

By HELLth Bill Slayer (not verified) on 18 Mar 2010 #permalink

Such polls are highly speculative in nature because they are asking these doctors what they might do and people often exaggerate their responses to questions when they are frustrated and will not be held accountable for their comments.

I also agree with the commentary that few people in any profession are simply able to change jobs on a dime. While some doctors may not like the changes, most will simply vent their frustration and keep on doing what they have been.

What's worse the assface democraps are vowing now to let the Bush tax cuts expire which means I will have less money every money. Instead of getting a pay raise, I will get a pay decrease. I guess I will have to retaliate by taking the amount of money that I lost and giving that same amount to a law firm that will be sueing over this health bill. Every time the overnment costs me money I retaliate by giving that same amount of money to an organization that fights liberalism and big government. This year i may retaliate by giving it to the Landmark Legal Foundation, or Liberty Counsel, or better yet, the liberals' favorite charity ... drum roll please ... ANSWERS IN GENESIS. Every time you liberals screw over my paycheck, I donate to anorganization dedicated to destroying your cause. I actively urge others to do the same. I can't legally fight back with weapons, actually under the second amendment I could but wouldn't get very far, but I can fight back with money, blogs, and the internet. I refuse to be a victim of government slavery. I have vowed that every time my freedom sovereignty, and independence is hit, I will hit back twice as hard and for twice as long. It will be a long battle, but the end will be beautiful. Socialism killed, wiped out, and buried with evil demons of hell that inspired it.

By HELLth Bill Slayer (not verified) on 18 Mar 2010 #permalink

Hey HBS: If you truly are in the business for the sake of "helping people", that line you deploy at school interviews- remember it?- then you should be happy to be free of HMO's and happy to see the worst of the worst-off finally getting access to care at any level. The rest of the world seems to do just fine with assorted levels of Govt. sponsored healthcare, not to mention the human benefits of preventative care that universal access promotes. Sure every system has its problems, sure people want to be paid more. Maybe the Doctors should talk to the nurses, NP's, PA's, assorted therapists and allied professionals to understand actual, rather than assumed underpayment. These people take the brunt of the patients' frustration with the system, and still struggle to pay the rent. And because they're not "The Doctor" they get treated like crap by everyone. Check your privilege, spoiled brat.

I refuse to be a victim of government slavery

by remaining a victim of catastrophic brain trauma.

Perhaps stem cell treatments can help you?

Battling socialism?? Hardeehar. Where you headed TuffBad? Sweden?

By El Picador (not verified) on 18 Mar 2010 #permalink

Health Bill Slayer:

I think your moniker is a bit overreaching. Entering the halls of Congress and obliterating the health care reform bill seems a tall order for a grammar-challenged blog commenter. I think you're out of your league, Skippy. Maybe you should head back to your tea party and hoist your ridiculous sign aloft.

I do commend you on your ability to parrot Fox News/tea party lies talking points about this weakened compromise that is the current health care reform bill under consideration.

Let's set the record a little straiter, shall we?
1) The HCR proposal isn't even within ballistic missile range of a "government takeover." It's still private-practice providers, for-profit health insurers, etc. There's not even a public option. In my opinion a government takeover, á la Britain, would be an upgrade. Under "socialized" health care, no one goes broke paying for health care, and everyone is covered. Think of the opportunities this opens up: entrepreneurs could strike out on their own without fear of going uninsured. Employers would have to compete for workers based on something other than health care, because everyone would have it. GM could lower its per-unit cost of manufacture, since it would no longer include health care in the cost basis. Everyone wins!
2) The Bush tax cuts were disproportionately granted to the wealthiest among us. So while you may have paid $20 less in (federal income) taxes, filers with earnings of over $1 million paid thousands less. As a result, schools can't pay for necessities and pull money from the students' families in the form of fundraisers and donations. This is what we call a "hidden regressive tax." It's also why our roads, water/sewer, power grid, and public safety infrastructures are crumbling.
3) I see your also a "tenther." Just so you know - the tenth amendment does not grant the right of states to opt out of federal statutes with which they disagree. Please tell me your also a "birther" and "deather" so we can call it a trifecta!
4) If it is "freedom sovereignty and independence" you seek, there are FAR better places to go than the US Might I suggest Sudan - no functional government, no taxes, and all the guns you want! You could make your own little fiefdom! The plain fact is that you wouldn't even consider it, because you can't live without those things that liberals have enshrined in our society â fresh water, reliable power, ample roads, safe streets, clean air, etc. Those infrastructures are hard-won achievements of liberals who had to overcome considerable conservative opposition at every turn.
5) Pray to your imaginary sky-god all you want, Sport. It gives you the false impression that you're doing something, and keeps you from parroting Faux News talking points. In fact, go pray now. Spend all your waking hours praying instead of stalking blogs.

As for the original point of Pal's post - I take the physicians' express desire to leave the medical practice upon passage of health care reform the same way I took the proclamations of liberals who vowed to emigrate to Canada should Bush get reelected country: all talk; no action.

T-FLAP, do not mock TuffBad!

By El Picador (not verified) on 18 Mar 2010 #permalink

I realize there is a shortage of primary care physicians, and that they would be overwhelmed if anyone could get care. Fortunately there are a lot of physicians assistants and family nurse practitioners out there, and tons of people in school for those professions. It is a fast growing profession with an extremely practical function. I am pretty confident that they will be able to handle the extra work. They all need MDs to supervise their work, so they won't replace doctors either.

HBS kinda tipped his hand with the sodomites reference. This is basic us versus them mentality.

He doesn't understand the first thing about the health care industry or the current overhaul plan. He just knows that it's supposed to be "them" taking over.

I dunno though, I just find this exceptionally, mind bogglingly weird. Christianity is being used as a tool to lobby against health care? Wha??? Did I miss the part of the bible where Jesus talks about letting the poor die of their illnesses and caring for the wealthy instead?

Look, I know Beck made that well publicized statement telling people to abandon any church that mentions social justice, but I kind of expect absurd statements from him. But people are actually buying this? Caring for the poor is now against Christian values? A mormon talking head on Fox is able to convince people to go against the basic teachings of Jesus while making them believe they're still following the principles of their faith which are supposed to be, ya'know, based on the teachings of Jesus?

"Caring for the poor is now against Christian values?"

It's more that certain fundamentalist denominations position on the theology of government maintains that caring for the poor is not part of the institution of government--rather it's a function of the church. Thus, having the state provide charity would be for the state to overstep the authority granted to it by God. Charity is a duty, but it should not be mandated by the government. Instead, instead it should be voluntary.

In essence, it's more about how they believe the world should operate than how it actually does. Obviously, many other churches disagree with this sentiment.

If my doctor were willing to quit because of making one penny less, then I'd be glad of it and consider myself better off without her. I wouldn't trust the care I'm getting from someone who is so greedy that they prioritize money over everything else. I'd rather go to an overworked but benevolent doctor than to one who cares nothing about me except how much money I am giving them.

If we do have a shortage of PCPs, I'm not so selfish that I would wish that many people have no access at all just so I can get mine. But I actually care about my fellow citizens, which is apparently a radical idea.

I'm kind of ready to call Poe on HBS, but it's a good Poe so it's hard to tell.

Unscientific survey with an N of 1: Currently, I am looking for jobs outside the US because the US does not have a decent health care system and private insurance is really just too much trouble to deal with. No matches yet, but I'm actively looking. If health care reform passes it'd make life a bit easier and take the edge off the desire to leave.

Doctors' reimbursement levels are going to go down in the US whether health care reform passes or not. Insurance companies work as effective monopolies and they have decided to pay less. Along with medicare. And it's true that medicare is quite insane at the moment...if anyone is fool enough to encourage me I might explain the "consult" saga to you...but at least they do have a set of rules that can be followed with consistent results. Unlike private insurers which are all over the place and completely random. I'd rather deal with a government bureaucracy full of indifferent people than a private insurance bureaucracy full of actively hostile people with a vested interest in not providing coverage for necessary care. Excuse me, I'm off to surf the Canadian job ads now.

if anyone is fool enough to encourage me I might explain the "consult" saga to you

I'd be interested in hearing your explanation.

If HBS isn't a Poe, he's a moron.

From what I can find out about the bill that is apparently about to be passed, it seems it will be actively harmful for just about everyone sooner or later, poor and rich, healthy and unhealthy, young and old.

I am not saying that the country doesn't need health care reform, I'm just saying that I think this bill is worse than doing nothing.

If the current legislation addresses the problems related in this article, The Cost Conundrum, I wish somebody would point out how.

@19: Here's what happened, as far as I can tell. Note that I only see the end effects, not the process by which the decision is made, etc. Also just to note that I'm talking about inpatient care only below.

For several years there were mutterings about how consults were coded wrong and that the code might go away if people didn't start using it correctly. This year, medicare has decided it will no longer pay for care coded as a consult. Fair enough, I suppose: if, as claimed 80% of people were doing it wrong, maybe it's not a very useful thing to have.

However, they still acknowledged that specialty care from a different provider than the primary MD of the patient should be acknowledged to be different from routine day to day care of the patient by the primary MD who already knows the patient and the history of the hospitalization so far. That's nice, I'm glad they're taking that into account.

Now, here's where it all goes crazy. The medicare solution to this problem is to have consultants bill patients for an initial hospitalization when they are seen. No matter how long the patient has been hospitalized. In other words, in order to code correctly for medicare, you have to lie. I know that everyone will know what's going on and so forth, but it bothers me that this required, instituational counterfactual has been set in place. Why not just reduce compensation for consults a little so that they aren't so attractive for fraud? Or make a new code for "subsequent hospital day" that indicates a new type of service? Or just about anything that doesn't involve outright required fraud?

From what I can find out about the bill that is apparently about to be passed, it seems it will be actively harmful for just about everyone sooner or later, poor and rich, healthy and unhealthy, young and old.

In what ways? What aspects of the bill do you think will harm people?

Hey A, comment number 3: I'm a banker, have been one for 25 years, and no, it doesn't pay better than medicine. Now if you meant INVESTMENT BANKER then yeah, if you live in NYC and work for one of the big firms, it does pay better. And now the American taxpayers are helping keep those salaries up with all the bailouts of Wall Street firms.

By Anonymous Reader (not verified) on 19 Mar 2010 #permalink

@22, Dianne -- One way it will harm is that it likely will perpetuate the kind of problem you describe in #21. Since it's far too big for anyone to fully know how the various aspects will fit/work together, I think it's likely to make things like that worse. It's far too big and there have been too many patches and fixes. Such ambiguity invites corruption.

** Note, everything I'm writing here is speculation, but frankly that's all I'm seeing anywhere. Though I'm tired of hearing it asked, I still haven't seen an answer to "Has anybody read this thing?" much less has anyone understood it?"**

But -- just for argument's sake, let's take this article for starting argument:
What's in Health Care Bill?

1. The $940 billion cost is staggering. The increase in coverage minimal in comparison, a 12% increase, still leaving 5% of the population not covered - about 16 1/2 million people.

2. It contains an exemption from the requirement to be insured for low income people. Wasn't one of the purposes of the whole thing to provide health insurance for those who currently couldn't afford it?

3. The insurance market reforms are not financially feasible. Mandating coverage always increases costs and this allows no method of recovering the costs except higher premiums for everyone involved.

4. Medicaid expansion - is this going to cover the poor people listed in number 2? If so, why is the total expected coverage still only 95%?

5. The Medicare tax on investment income will not raise as much money as predicted as it will have the effect of reducing investment, which will in turn reduce the number of jobs that pay over $200,000/yr thus further reducing the tax dollars brought in.

6. Employer responsibility. Part of the supposed good thing about Universal healthcare was to level the playing field with international companies. This fee pretty much negates that goal. Furthermore, tying health insurance to employment is one of the things that got us into this mess in the first place. Yet, little in the bill seems aimed at remedying that.

7. (not addressed in the CBS article) As far as I can tell, there's no provision to dedicate the funds from the additional taxes to pay for the bill. If I understand correctly, the taxes start immediately and the provisions of the bill are phased in from now until 2020. Theoretically, this is to allow enough money to be collected to pay for all the provisions, but the money is going into the general fund. We'll end up with the same or worse financial situation as we currently face with Social Security and Medicare.

There's more, I'm sure.

But the main thing wrong with the bill that I can see, is that it does not address costs associated with the delivery of health care. It's all about paying costs that will essentially stay the same or rise. How does adding massive layers of bureaucracy onto existing costs reduce them?

The link to the New Yorker article I included in my comment #20, contains some examples of ways to do that, but I don't see where any of those are contained in the bill about to be passed.

I would love to see someone point out where CBS is wrong or where I'm misunderstanding something else.

Free America from this socialist takeover!


Sometimes I think it was wrong to bring a child into a world with so much stupid.

@Health Bill Slayer
"Two of them has vowed to seek a new profession if they are payed one penney less due to this bill. That's half in my town."

Did they have a clue what profession they would find that would compensate them at a level anywhere near what they are currently earning? Where are all these unfilled, high paying positions going to come from? Perhaps you haven't noticed there aren't a lot of jobs of any kind to go around right now.

Even if unemployment weren't high right now, you're talking about a large pool of people all competing for new careers with each other as well as others already establish in those fields. What people say they will do and what they actually do often have very little correlation. Lots of people talk the talk, few walk the walk.

Damn! Now I'm going to have a couple of Doctors trying to get my "greeter" job at Walmart.

By nitramnaed (not verified) on 19 Mar 2010 #permalink

BTW. The trolls said the same thing about Canada's "Real" healthcare reform. Guess what.....there wasn't a run on "greeter" jobs their either.

By nitramnaed (not verified) on 19 Mar 2010 #permalink

I've been following this topic for a couple of years - even though I'm a British guy working in Canada outside the medical profession!

The bill is not amazing, but it's way better than doing nothing, if only because it will end recission (where you can be denied coverage after you get sick). It will also reduce the deficit, according to recent scoring by the Congressional Budget Office.

There are lots of good things in it, and some not so good things. It's not perfect, but it's a start.

Nomad, thise who doubt the existence of Jesus doen't ge tto discuss His teachings. You first must believe, then you can discuss the matter. Jesus did not teach everyone to surrender their right to the government in the name of taking care of the poor. he specifically told individuals to give of themselves to help the poor. Nowhere in his teachings did he mention government taking care of the poor. That was the job of the church, not the government.

He taught individual(not collective) responsibility, individual salvation (not collective), and gave people an individual (not collective) choice in following Him or not. He taught people to take care of the needy and the sick. He did not teach for people to give their lifeblood over to the government and let the government do it as a collective source of product. Jesus was the Son of God, not a socialist tyrant. Remember how His followrs hated tax collectors? Well, nothing has changed.People still hate tax collector tyrants. Two tax collectors gave back their taxes to the people from which they took after following Jesus. Mayeb we can get them to do it now. Now, do you wish to follow His example or do you just follow it when it is convenient for you?

Oh yeah. Stop making up letter to represent my post name. Call me by my name. Are you so lazy that you have to abbreviate everything? I have an idea. Let's take away the health care rights of those who are too lazy to even spell out words, becuase if they are too lazy to spell out words, the they sure as hell don't want a job.

By HELLth Bill Slayer (not verified) on 19 Mar 2010 #permalink

If anyone's keeping track, HBS is also "Dr Smart" and various other socks, many of whom spew antisemitic and other hate speech here.

Some day his folks will let him out of the basement, but not until he stops messing himself.

Oh, and his IP address, assuming he doesn't know how to spoof it via proxy, is in Madison, WI.


" Two of them has vowed to seek a new profession..."

I can has cheeseburger? (The proper verb is have.)

"If I had a child who was considered a career..."

I was had cheeseburger? (The proper verb here is considering)

"The government sure as hell isn;t going to give the doctors what they deserve and a doctor working forhimself cannot make it on his own very well these days..."

You need an apostrophe instead of a semicolon in isn't, the sentence needs a comma after deserve, and there's a space missing between for & himself.

"Just the innocent people."

Fragment sentence with no verb.

And that's all just from the first comment. If you take the time to either learn proper English or proofread your comments before posting, maybe you won't look quite as silly or hypocritical when you criticize someone as lazy just for abbreviating your post name.

Jesus didn't write English too good either, Karl. What about that?

By MonkeyPox (not verified) on 19 Mar 2010 #permalink

I do not know Palmd's IP address or location . I do not post hate speech. That's the job of MSNBC. Nice chatting with you though. I am surprised I haven't been censored yet. Grammar is irrelevant on fake "science" and other unimportant blogs. It is only relevant when the topic is important. BYE.

Usually other liberals' websites are boring. They all talk about how to plug up a cow's ass in order to stop global warming and such unimportant and useless stuff like that nonsense. Sorry Plamd. You site has interestig posts. If you do not want me commenting here, then I will stop. I'll just read the posts and make comments about it on my own site. Is that fair? Goodbye.

By HELLthbill slayer (not verified) on 19 Mar 2010 #permalink

The bible only mentions Jesus writing anything once, and that was written in the sand. I think it's safe to assume it probably wasn't in English.

You have just earned the newest Jody award! It's a special award I bestow on web commenters based on my most favorite comment I have ever seen in a blog or forum. It was originally posted in reply to a comment similar to your #35.

âAnd the moral we learn from that last comment, Boys and Girls, is that if you canât win an argument on its merits, take a shit on the desk and leave.â

-Comment by someone named Jody in a thread on skeptico

The new "reform" bill may not cause physicians to flee, but the medicare pay cuts that went into effect on March 1 certainly seem to be doing the trick. Pal, I recall that you already opt out of new medicare patients.

The problem with government-sponsored healthcare in the US will be that the overall funding level would be controlled by politicians, many of whom love to cut spending without understanding what is being cut, and who suffers for it.

There are a large number of physicians who will be more than slightly effected by this legislation. These are docs in their late 40's on up who are in a fairly decent position financially. They might feel persecuted, and perhaps rightly so, from all the ways they are targeted by this legislation. Not only will there be fee reductions but a plethora of new practice rules to follow. No malpractice reform. Add extra taxes that will come into play for those making "too much" not only on their wages but investments as well. This is not just about insurance companies. It is also about squeezing docs. I think as the changes kick in some of these docs will retire from medicine to pursue other interests. They will have the financial ability to do so even if that interest or hobby only pays a small fraction of what they made as docs. I don't think there will be a sudden large exodus immediately with passage but I think there will be a significant accelerated attrition as reduced pay, increased taxation and increased workload take effect. Worse perhaps, this will be taking the most experienced practitioners out of the field.

I get the basic picture of the current plan is that it's not too pretty.

But it should still be better than the situation we find ourselves in now. And if it's allowed to die that's it, we've got ourselves another decade of waiting or so before anything else can ever be done about it thanks to the job those opposed to this have done sabotaging it.

And given the current trend I shudder to think where we'd then. I want to suggest, in jest, the image of a blighted landscape dotted with gold encrusted hospitals surrounded by tent cities occupied by the masses who have to spend all they make in the sweat shops just to fund the hospitals.
Instead of tax collectors they face the health insurance collectors that come around once a month to steal those last pennies that they were saving for a loaf of bread.

I know that's silly, presumably at SOME point it'll get bad enough that something would have to change.. But that is how I've seen this bill cynically characterized. Of turning people into serfs of the private insurance companies. Surely people are eventually going to realize that those socialist Europeans are managing to get effective health care at a fraction of the cost and wonder why...

But I'm not holding my breath for it to happen any time soon.

Some of our health care statistics are dropping right out of the levels of the other first world nations and are starting to enter the realm of the poorer countries. I really don't know how low it'd get before enough people start to notice.

Have you discussed personal finances with many MDs in their late 40s, or are you just speculating as to their likely financial positions?

The ones I know of aren't very close to paying off their home mortgages, haven't had their student loans paid off very long (if at all), and have one or more kids still to hit college. I don't think I know any MDs shy of their late 50s who could realistically afford to retire.

Even for docs currently in their 50s, it could be difficult. A lot of people in their 50s still have mortgages with 10 or more years left on them ( and no real ability to trade down for a smaller home right now) and a kid or two still in college. Additionally, there's a lot of people around these days that can't afford to retire early due to the massive correction the market has taken due to the housing bubble. People's retirement savings have been decimated (some literally so), forcing many to push back anticipated retirement dates.

I really don't see this mass exodus from the profession happening. I could buy into the plausibility of the speculation that there might be a reduction in the number of people who choose to enter the market (go to medical school) and a reduction in the number who choose to enter primary care, neither of which are desirable.

Donna @24: Admittedly, I haven't read the bill. (A friend of mine claims that one of the major problems with it is that it's so large that it can't reasonably be read, but that's a different issue) so I'm responding more to what you're telling me is in it than from actual knowledge of what is in it. With that caveat and admission out of the way...
1. 12% is a huge increase in coverage! Currently that 12% of the population is a total write off if they get sick. That is, the hospitals eat the cost and pass on the loss to those with insurance and/or the taxpayers. So although the initial cost is high, the net cost should be low. Remember, few countries pay as much in public money for health care as the US does (I think Switzerland pays slightly more per capita but that's it) so almost any reform that can remove the burden of paying for the uninsured is likely to be a money winner in the end. Note that I am putting in a lot of weasel words because ...well, Murphy's law applies to congress.
2. Beats me what that exemption is about. Sounds like a bad idea on the face of it, but again if we can get that 12% under control coming back for the other 5% may seem less overwhelming.
3 It works for auto insurance. Why should health insurance be different? (For all I know there is a good answer to this rhetorical question, but the fact that we have an example of a workable mandatory insurance system in existence makes me doubt that the problem is as insurmountable as you are presenting.)
4. My guess is that the leftover 5% are illegal immigrants, tourists who get sick, etc. I agree that leaving them uncovered is a bad idea but rejecting a bill that covers 95% of the country when only about 80% is currently covered seems to me to be letting the best be the enemy of the good.
5. This is a lauffer curve argument, if I understand correctly. Has any country or tax anywhere ever been demonstrated to be on the left side of the lauffer curve? Until it is, I'd consider this a theoretical problem at worst.
6. I agree that decoupling insurance from employment would be a good idea. I'm not convinced that the failure to do so is reason enough to reject the current plan. Again, if people are covered whether they are employed or not that makes completing the decoupling look less insurmountable.
7. Social security doesn't come from the general fund. Myself, I'd like to fund health care reform by canceling a war or two, but I'm probably just a crazy peacenik. Personally, I'd feel happier about paying taxes if I felt I was getting something for my money...like, say, health care coverage for most of my patients. It's when the money goes towards killing people or inventing ever more ridiculous travel restrictions that I get irritated.

I'm calling Poe on HealthBillSlayer.

By Katharine (not verified) on 20 Mar 2010 #permalink

Pal, why don't you set up a dungeon much the way PZ does so you can condemn people as repeatedly wacky and unable to actually talk as HBS/Dr. Dumbarse to it?

By Katharine (not verified) on 20 Mar 2010 #permalink

I'm just waiting to find out what the rules are going to be so I can adapt my practice to them.

By The Blind Watchmaker (not verified) on 20 Mar 2010 #permalink

I recently checked out an anti-healthcare-bill forum for physicians on Facebook, and encountered plenty of rhetoric at least as heated (and grammar at least as bad) as Hell-BS. Lots and lots of complaining about how the gov't can't do anything right, how the bill will put a third party between a doctor's decisions and a patient's care, how the nation is on a path to socialism.

My first thought was, these docs can't possibly accept insurance anyway if they are so fired up over a 3rd party second guessing their decisions. And as far as I know, the bill does nothing that affects docs who collect fees directly from patients and don't accept insurance.

In any case, I see no reason whatever to assume Hell-BS is a Poe.


The problem with government-sponsored healthcare in the US will be that the overall funding level would be controlled by politicians, many of whom love to cut spending without understanding what is being cut, and who suffers for it.

And this is different from private health insurance... how? At least government officials (nominally) report to voters instead of stockholders.

As a Canadian, I truly don't understand the objection in the US to the very MODEST changes being proposed to your already excessively burdensome system.

You already have health-care rationing - but right now it's in the hands of people who think that medicine should be a for-profit enterprise. Somehow that's a better system?

By CanadianChick (not verified) on 21 Mar 2010 #permalink

Dianne @41 - I agree with your friend that the bill's size is one of its major problems. Apparently Canada was able to implement its universal health coverage with a 14 page bill.

1. I guess we'll just disagree that a 12% increase in coverage is worth the cost. But, as you say, we're paying for their care now anyway through write-offs, so how is insuring them going to make it cheaper? I really don't understand that part. It looks like cost shuffling not cost reduction.

2. It should be explained who is exempt and why. I think it's very sad that you, your friend, and I should have to wonder what it means.

3. What's mandated in auto insurance is liability only. That's not comparable to the health insurance mandate. If the health care bill mandated only catastrophic coverage for accidents, it would be somewhat more comparable. Auto liability insurance is closer to malpractice insurance than to health insurance.

4. Again, I have a problem with both of us having to guess what's in the bill. One question I have is whether the proposed reform will be elastic enough to provide the care that illegal immigrants now get. I would imagine that tourists make up a very tiny % of the uninsured. If I could be even halfway convinced that this bill is good and will cover 95%, I'd be fairly happy.

5. Are you saying that all countries and all taxes are on the right of the laffer curve? I am not an economist (if you require proof of that, I can send a financial statement!) but it seems to me rather obvious that taxation can be increased to the point where the incentive becomes to earn less rather than more.

6. I see it differently -- I think decoupling is a requirement for the universal health care to ultimately work, and as far as I can tell, the current proposal actually makes the coupling stronger, not less so.

7. Social Security was supposed to be a separate fund, so Congress had to jump through some hoops to borrow from and now they've cleaned it out haven't they? With this proposal, there's not even a pretense to put the money anywhere except in the general fund.

Well, too late now, it passed. Now we can see if anyone actually does quit, leave the country, or whatever else they're threatening to do.

@ Dianne: maybe Rush Limbaugh will keep to his promise and re-locate to sunny,more-stuff-is-legal-here Costa Rica?(we should *be* so lucky!)

By Denice Walter (not verified) on 22 Mar 2010 #permalink

But Costa Rica's a nice country. They don't even have a military. How could they handle Rush?

Dianne,I'm sure the pharmacists will think of something.

By Denice Walter (not verified) on 23 Mar 2010 #permalink

"This is a lauffer curve argument, if I understand correctly. Has any country or tax anywhere ever been demonstrated to be on the left side of the lauffer curve?"

Since the laffer curve is a fictional thing, this question is the same as asking "Has any person ever been demonstrated to be on the left side of a unicorn?"

Just a comment: if we thought the senate and congress were areas of pettiness and loggerheads before, I have a feeling we "ain't seen nothing yet". McCain's promise to completely stop working with the white house, and the voices of others to do everything they can to repeal this, will lead to nothing more than a whole lot of serious ugliness.

HBS - didn't your Jesus supposedly say that his followers shouldn't argue with their government?

Look for a surge in Concierge care. PCPs will opt out of the standard system and people will buy in rather than sit in waiting rooms all day. My husband and I signed up today and will have quality healthcare partner PCP who is one of the best in the city. He will be sending 2000 or so off to find other doctors. That will be the net impact of healthcare reform. Pay up or you will take weeks to get an appointment if you can find a doctor.

Greta, I'm guessing you don't have a clue about how most people get health care, especially those who cannot afford to pay into a concierge practice. Step outside your box.

I wonder if the government can't step in to alleviate education and startup costs for PCPs as an incentive. Came from a very small town, where in the 40's- 50's the public health service, or some variety of it,provided the funds to build a clinic to house a GP and dentist.

What would be the problem with establishing low interest medical education loans, with the condition that the principal would be decreased proportionately for practice in underserved areas? It was done when teachers were needed in the 50's and 60's.

It is amazing to me the number of people who don't have the slightest idea what "government run healthcare" actually is. I'm more amazed that people don't understand the difference between health insurance and health _care_, but half the country believes the earth is younger than Niagra falls, so what do I know.

The real reason most people are against this has nothing to do with all this esoterica, its actually very simple: they think anyone who doesn't have HC right now or can't afford it is because they are lazy welfare queens/kings. Never mind how asinine such a view is, that is what they think. Never mind that the average person is unlikely to see any significant difference in their plans if they already have coverage through their employer. Never mind that the average persons taxes will be unaffected. They have been immunized to evidence and they like it that way.

And any "Christian" who says they are frothing over this because their church should be providing the charity and not the government is a bald faced liar. You don't get that mad because someone else is helping the person you want to help yourself.

By skeptical (not verified) on 24 Mar 2010 #permalink

If anyone says they're angry because their church should be providing the charity instead of the government, I want to see evidence that their church has done so, in all the previous years when this plan wasn't in effect. Numbers, please. How many visits to doctors or nurse practitioners did their church fund? How many people's medicine did it pay for? How many surgeries? And how does that compare to the number of people in the area who have neither other medical insurance nor the church covering their medical bills?

I can understand why doctors are so upset. Sure they make a lot of money but they are also buried in debt. Obamacare will probably lower doctor salaries, but med schools will continue to raise tuition through the roof.