Senator and presidential candidate Kamala Harris took a page out of President Obama’s book when she said last week on late-night TV that patients would be able to keep their doctor under her Medicare for All plan. It showed her lack of understanding of a fundamental truth — that health insurance is not the same thing as health care, that doctors have choices, too. At best, health coverage means access to health care; at worst, it is a false promise. And if our system is suddenly transformed into one that is overloaded with a high-demand, low-reimbursing clientele, you will be lucky to end up with any doctor (or nurse practitioner), let alone the one you started with.
There is already a growing doctor shortage in the U.S., and it is only going to get worse. The Association of American Medical Colleges predicts that under the current system we may be over 100,000 doctors short by 2032.
And this shortage is especially a problem when it comes to public health insurance, so imagine what it would mean if we expanded Medicare to cover all. In the U.S. currently, with less than 40 percent of the health-care system in public hands, nearly a third of doctors won’t see new Medicaid patients, and Medicare patients frequently have difficulty finding a new primary-care doctor. Public health insurance is more cumbersome and difficult for both doctors and hospitals, and it pays us much less. Most of us try to limit how many Medicare and Medicaid patients we see.
Senator Harris has seen this problem reflected in her own state of California, where one out of three people are now receiving Medi-Cal (California’s Medicaid program), as a result of Obamacare’s Medicaid expansion. But just because you have Medi-Cal doesn’t mean you have access to a doctor. In fact, the growing physician shortage has especially affected the poor. In response, Governor Newsome has just allocated more than $300 million to provide free tuition for medical students provided that one-third of their patients are Medi-Cal patients for five years after they graduate. As someone who participated in a similar loan-forgiveness program in New York State back in my training days, I see this as a small step in the right direction, but it’s by no means a guarantee that doctors will continue caring for Medi-Cal patients after their payback term is up.
Here in New York, my medical center, NYU Langone Health, is using donations to provide free tuition for all medical students. The statistical results of this amazing experiment aren’t in yet, but many of these students appear more open to primary care as a profession because they know that they won’t graduate with huge loans to pay. Other medical centers are now copying this model, and I believe it will be a far more effective approach to the primary-care shortage, especially if more medical school spots are also opened up.
In the meantime, we lack the primary-care doctors to administer the current government-run health-coverage programs, without asking us to take less money for dealing with the delays and care rationing under a system of Medicare for All. An average primary-care doctor in the U.S. in 2018 made $223,000, which isn’t a lot when you consider the many years of training and the growing time demands of an electronic record-keeping system. In Canada, which has a single-payer system, the average primary-care doctor makes $200,000.
Consider how much more difficult it is for a primary-care doctor like me to practice medicine when there are long waits, and specialists aren’t readily available. In Canada, patients typically must wait several months for everything from MRIs to CT scans to dermatology appointments to hip replacements to cardiac stents. Imagine how much pressure that puts on the referring general doctor as well as the patient, who struggles to receive care and often risks adverse outcomes and suffers discomfort while waiting. General practitioners end up being forced to diagnose and treat conditions they would prefer to leave to specialists.
A Medicare for All system here in the U.S. would place the same kind of burden on doctors and hospitals. The shortage of doctors and nurses would grow, especially without an associated plan to greatly expand medical education and make it easier to obtain. Even former vice president Biden, who doesn’t support Medicare for All, instead proposes expanding Obamacare subsidies, creating a large public option, and putting a cap on premiums — all of which would create an additional burden on the health-care system without considering the essential shortage of care available.
No matter what your plan, you simply can’t pay doctors and hospitals less to do more while rationing essential services. That would be a poison pill for the health-care crisis, not a solution.