All Commentary
Tuesday, November 3, 2009

Not with a Bang But a Whimper

What healthcare “reform” will mean

Social change can be revolutionary, sudden, and swift. More commonly it moves at a glacier pace. Yet glaciers work great change, and great damage, given enough time.

There is much talk of doctors’ leaving their profession if ObamaCare—that is, burgeoning government control of the practice of medicine—passes. However, the odds are great that although ObamaCare will pass, there won’t be any dramatic job stoppage. No Galt’s Gulch will form where masses of physicians on strike will live in peace and solitude, some building cars and others mining copper, all vowing never to return to medicine until their demands are met. Such is the nature of fiction. But the reality is much worse.

What will happen will be more insidious, though over time no less damaging. There will be an increase in early retirement, as more physicians tire of their jobs.  More will take time off and let their practices suffer at the margin. Patients will have slightly more difficulty making appointments each year–year after year–though never so quickly as to lead to mass complaints or a recognition that things are obviously worse.

Coverage will be shunted to physician assistants, nurse practitioners, emergency department physicians, hospitalists, and partners. Fewer patients will feel they have their own doctors. This will not necessarily be worse—I don’t feel I have my own McDonald’s, yet the food remains as I expect—but it may be worse to the extent quality of care depends on background knowledge of individuals.

And the filter determining who gets into medical school will change. Fewer will enter the field due to intellectual curiosity. More and more people who cannot tolerate bureaucracy will be weeded out. Questioning authority will become as dangerous in medicine as in policing or the military. The 40-hour physician work week, on the other hand, will become commonplace, and the type of person attracted to medicine will not be the type willing to work any longer or any harder.

Slowly and gradually, community hospitals will resemble VA hospitals. Centers of excellence will be advocated in theory—“evidence-based medicine” will be the byword to “bend the cost curve downward” by eliminating “inefficiencies.” But will they really be excellent, or will they merely be better than whatever else is available? Will they be free to innovate? Will they be free to profit if their innovations are successful? Or will they simply be the medical equivalents of the best cars on the road in Cuba?

Pharmaceutical innovation, produced by those evil for-profit companies that even doctors love to denounce, will drop off–not precipitously but eventually. And people will die, as they have died from time immemorial, without anyone ever knowing what drugs might have improved or extended their lives, if only there had been greater incentives available to produce them.

Imaging studies will become more important, as fewer physicians learn how to do detailed physical exams—it’s not as if they’ll have the time per patient to do such exams in any case—but imaging studies will also become more difficult to schedule. And the quality spectrum between optimally interpreted exams and standardly interpreted exams will continue to widen. The CPT (Current Procedural Terminology) codes are the same, independent of the quality of the interpretation.

There is already a spectrum of quality available in medicine, and those with means can obtain better medical care, just as O. J. was able to obtain better legal services. But that spectrum risks becoming more rigidified. What in America has been health care for the poor will become healthcare for all but the very rich. But the “cost curve” will bend downward.

Or will it? Medical salaries will bend downward, certainly. But administrative costs associated with government programs are always huge, and always underestimated. Medicare spending now is an order of magnitude higher than the projections made in 1965. But we do know this: Bending the cost curve of medical care in either direction has costs of its own.

If it’s bent downwards people will wait longer for health care that is not as good as it could have been. We often buy things “not as good as they could have been”—Chryslers rather than Cadillacs, Range Rovers rather than Rolls Royces–but we make those choices at the individual level; they’re not forced on us by “society.”

Or the cost curve can bend upward, perhaps due to hidden governmental administrative costs, perhaps because AARP is a strong lobby. And we’ll feel the pinch in other areas, as our debt grows and our prosperity lags and falters, and becomes a quaint piece of history we teach our children (or perhaps, in our guilt, hide from them).

We’ll pride ourselves, as we do now, on “the best healthcare system in the world,” as we also brag that we have universal care, just like the great nations of Europe. And we’ll suffer with double-digit unemployment, just like the great nations of Europe. And we’ll have lower productivity growth, just like the great nations of Europe. And we’ll have smaller houses and cars, just like the great nations of Europe.

But it will be all right, because we’ll have a right to health care . . . for which we’ll wait . . . and wait . . . and wait.