Wednesday, December 03, 2008

The Medicare Miracle That Isn't

Many advocates of single-payer health-care make the argument that the U.S. government should simply extend Medicate to all citizens. The elderly are overwhelmingly satisfied with Medicare, the argument goes, and so it is a simple matter to preserve all that is best with the U.S. health-care system - a free choice of a doctor with whom a patient can have a long-term relationship - while fixing what is worst - its unaffordability. I confess I do not know where the evidence that the elderly are satisfied with Medicare comes from. I suspect it is mostly argument by anecdote. When my mother turned 65 she was delighted with it, although whether she got the same quality of care she could've had had she (and we) been responsible for all her health care, as we were for her food, housing, and other essentials, is impossible to say.

But I have always had my doubts about how satisfactory Medicare really is, and know an offhand remark in The Portland (Ore.) Tribune has brought those doubts some support. Below are the money quotes:

Those waits already are long for many Portland patients, especially those with Medicare or Medicaid health insurance. Those providers don’t reimburse physicians at as high a rate as most private insurers.

About 45 percent of all Oregon physicians won’t even take new Medicare patients, according to McMullan. With a glut of patients and a lack of internists, McMullan says, they have begun rejecting the patients whose insurance won’t reimburse them as well.

As I suspected. With Medicaid this has long been known, but time-based (as opposed to money price-based) rationing may be endemic to Medicare as well. The article notes that it is happening too with some fully insured primary-care physicians (PCPs), although I suspect not nearly as much.

It is not correct to say there is a "shortage" of PCPs, as the article suggests there is, because that shortage has to be connected to some notion of willingness to pay, willingness to offer, prices and alternatives, and never is in such claims. But time-based rationing is almost certainly far more common among Medicare and Medicaid patients than among those paying cash or fully picking up the tab for their own health insurance (where it is probably zero), and than among patients with conventional employer-based health insurance.

In principle there is no objection to having more and more doctors be specialists, and fewer and fewer willing to be PCPs. Increasing specialization has been a hallmark of medicine, as with every other line of work, for centuries. There is probably nothing magical about PCPs per se, except that employers and insurers, in an effort to keep moral-hazard costs down, insist on interposing them as gatekeepers. That of course is a function of the fact that in the U.S. we treat health insurance as an opportunity to get others to pay for our routine health care, rather than as conventional (e.g., auto-liability or homeowners') insurance against low-probability, high-consequence acts. I think the more serious issue is time-based rationing of health-care treatment generally. And that, I fear, may be coming soon to a country near you.

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