Politics & Policy

The Health-Care Villains Nobody Wants to Talk About

The case against mandatory licensure of doctors

Have you noticed that health-care policy is a thing people talk about? There was this thing called Obamacare. I’m told that one party was not too happy about it, and a lot of people want to repeal it. And now, a lot of people are talking about what to do about health-care reform.

The debate about health care is important, and complex. But there’s one thing in the health-care debate that no one talks about, despite identifiable villains, money-grubbers whose actions threaten patient safety and increase the cost of care for everyone. Given such an easy-to-sell political stories, why isn’t C-SPAN full of congresspeople holding up cardboard printouts on the floor?

Well, because those health-care villains are also one of the most powerful lobbies in America. I am referring, of course, to doctors.

Doctors are real villains in the health-care system. The way the institution of medical doctors is set up in America is, in theory, everything conservatives are supposed to hate. After all, medical practice under United States law is a protected, big-government cartel. Access to the profession is regulated and restricted by law. And doctors use the power of this regulation to fatten their pocketbooks. Decades ago, conservative hero Milton Friedman made the case against mandatory licensure of doctors.

Doctors should, in theory, be villains also in the view of progressives. After all, doctors typically make a lot of money. Plus, medicine remains a male-dominated profession, and uncomfortably throwback dynamics exist between male doctors and female nurses in most hospitals.

Doctors enjoy all the effects of a guild. Restricting supply causes an increase in price, and I’m told health-care costs are a big deal. They have the power to resist reforms that can do real good. And as always in health care, the consequences can be measured just in dollars but in body counts. The doctor and writer Atul Gawande has done yeoman’s work documenting the tremendous toll taken by hospital-borne diseases, which kill roughly 100,000 Americans annually, and yet their incidence can be greatly reduced if doctors follow a simple checklist of easy and simple sterilization procedures. Those are changes that, as Gawande recounts, doctors keep resisting and challenging, even though they save lives and are nearly cost-free.

Decades ago, conservative hero Milton Friedman made the case against mandatory licensure of doctors.

The title “doctor” confers enormous mystique. Doctors exert disproportionate influence over the health-care system even though they are just one component of it and, being human, make mistakes. That the law regulates entry into their guild reinforces their disproportionate power.

But it’s not just about cost and influence. A third, newer way that medical licensure is bad for the health-care system is that it impedes innovation. Artificial intelligence, which is improving by leaps and bounds, is already better than doctors at providing diagnosis. Robots may or may not do what they will to working-class jobs, but they are certainly a threat to general practitioners. A plausible, and desirable, future path for health care, entails AI-enabled community health workers, or “super-nurses” (call them what you will), who provide many of the same diagnosis and prescription services that general practitioners now do and are freed up, thanks to AI, to provide more patient-centered and preventative care. It’s possible to imagine a future in which, like family doctors of old, your medical practitioners are people you know and trust, and who know you. You can reach through an app whenever you need them, and all for less than what your access to doctors now costs. But they won’t be doctors.

One reason why this isn’t happening yet is, you guessed it, regulation. To provide some of the services doctors provide is illegal if you don’t have “M.D.” after your name. So medical licensure should go. It’s practically self-evident. So why is it not even being discussed?

The answer, of course, is that doctors as a class are enormously popular with the general public. They enjoy a tremendous mystique, and everyone knows at least one doctor they like. Ending medical licensure would be a political non-starter. Thankfully, as an opinion journalist, I get to bang on the table and scream about policy no-brainers that are political non-starters.