Marketing Health Care

Massachusetts instituted what’s called a universal health care program — about 340,000 of Massachusetts’ estimated 600,000 uninsured have gained coverage, — and now supply is no longer adequate to meet demand. Kevin Sack writes in today’s New York Times

Once they discover that she is Dr. Kate, the supplicants line up to approach at dinner parties and ballet recitals. Surely, they suggest to Dr. Katherine J. Atkinson, a family physician here, she might find a way to move them up her lengthy waiting list for new patients.

Those fortunate enough to make it soon learn they face another long wait: Dr. Atkinson’s next opening for a physical is not until early May — of 2009.

A 13-month line for a physical? But the wingnuts tell us only Canadians have to wait in line!

In pockets of the United States, rural and urban, a confluence of market and medical forces has been widening the gap between the supply of primary care physicians and the demand for their services. Modest pay, medical school debt, an aging population and the prevalence of chronic disease have each played a role.

This is something I’ve written about before. The fact is that “market forces” have skewed the way health care is delivered in this country away from basic services like preventive care and emergency rooms. That’s because the real money is in providing boutique medical care products and services for those with means to pay for it. About a year ago, I wrote,

Basically, our health care system is good at delivering difficult and expensive stuff but blows at simple, ordinary stuff, like preventive care, compared to other nations. This means we save some lives that might have been lost in Europe, but we also lose lives that would have been saved in Europe.

How did this come to pass? Certainly we Americans value creation and innovation. But it’s also the fact that our private, profit-based health care system is very good at creating new health care products that will make a lot of money. But where there’s no chance of profit, forget it.

This is what the “magic of the marketplace” has given us. You know how markets work; where there’s a demand, someone will hustle to provide a supply, and competition encourages the creation of better products at lower cost. Our system is very good at creating new drugs and new technologies and then marketing them to hospitals, physicians, and even potential patients. And I’m not saying this is a scam; many of us have benefited from the drugs and gizmos. The problem is that some parts of the health care process just don’t make any money. And where it isn’t profitable, our system is falling apart. …

… Here’s what the “free market” people never seem to wrap their heads around: Unprofitable demands do not generate supply, even when those demands are desperately needed.

Put another way, not everything that’s worth having can generate enough profit to pay for itself.

… By now “market forces” have so skewed our health care delivery system that, even if we began to allocate our health care dollars according to need rather than profit, it would take years before the neglected parts of our system were built back up to where they should be.

Every now and then there will be a news story about our shameful infant mortality rates or our less-than-stellar life expectancy rates or that emergency rooms are closing or the number of hospital beds per capita is shrinking, and you can count on some wingnut to come out of the woodwork and declare that we are number one at delivering new drugs to colorectal cancer patients that increase their life expectancy by a whole 4.3 months, so take that.

One occasionally finds the claim that the U.S. has too many doctors, rather than a shortage of doctors. The problem is that the “oversupply” seems to fall short in primary care. Kevin Sack of the New York Times explains,

While fewer American-trained doctors are pursuing primary care, they are being replaced in droves by foreign medical school graduates and osteopathic doctors. There also has been rapid growth in the ranks of physician assistants and nurse practitioners.

A. Bruce Steinwald, the accountability office’s director of health care, concluded there was not a current nationwide shortage. But Mr. Steinwald urged the overhaul of a fee-for-service reimbursement system that he said undervalued primary care while rewarding expensive procedure-based medicine. His report noted that the Medicare reimbursement for a half-hour primary care visit in Boston is $103.42; for a colonoscopy requiring roughly the same time, a gastroenterologist would receive $449.44.

My understanding is that there are adequate numbers of medical students who graduate as general practice doctors, but since they carry an average of $120,000 debt for student loans they can’t afford to go into primary care.

This is unfortunate, because comprehensive health care reform requires better primary care so that health problems are prevented or treated at earlier stages. But in the U.S. “market forces” are better at creating and marketing expensive drugs and gizmos to hospitals to treat seriously ill patents. Ain’t no money to be made in preventive care. Money to be saved, yes, but not to be made. So emergency rooms rot, and people in Massachusetts wait 13 bleeping months for a bleeping checkup.

The situation may worsen as large numbers of general practitioners retire over the next decade. The incoming pool of doctors is predominantly female, and many are balancing child-rearing with part-time work. The supply is further stretched by the emergence of hospitalists — primary care physicians who practice solely in hospitals, where they can earn more and work regular hours. President Bush has proposed eliminating $48 million in federal support for primary care training programs. [emphasis added]

Of course he has. You can count on Bush to do exactly the wrong thing.

Anyway, just because real-world experience proves beyond a shadow of a doubt that “market forces” will not provide anything approaching halfway decent health care for all Americans doesn’t mean the wingnuts will lose faith in market forces. There’s no point even arguing with them. And because wingnuts dominate media, few Americans hear all sides of this argument. All they ever hear about are waiting lines in Canada.

Of course, the only reason we haven’t had worse waiting lines here is that so many people have been kicked out of the health care system altogether.

Be sure to read Paul Krugman’s most recent column, “Voodoo Health Economics.” GOP presidential candidate John McCain’s health care plan is, essentially, to allow the “magic of the marketplace” to provide inexpensive health care for everyone. Krugman explains in no uncertain terms why this is nonsense. The Boston Globe has more about McCain’s not-even-half-assed heath care proposals.

I’m not enthusiastic about either Hillary Clinton’s or Barack Obama’s health care proposals. They both fall under the heading of “better than nothing” in my book, McCain’s proposals being “nothing.”

The two Dems may not be beyond hope on health care, however. From an editorial in today’s Toledo Blade:

At one time or another, both Senator Clinton and Senator Obama have said they could support a single-payer national health insurance system, a kind of “Medicare for all,” as a solution to the health care crisis, but they have apparently calculated that it is not politically feasible to advocate it today.

The new survey of the nation’s doctors suggests otherwise.

These findings dovetail with those of an AP/Yahoo public opinion poll last December showing 65 percent of Americans favor a similar approach.

National health insurance is not only necessary, but increasingly popular.

Winston Churchill is remembered to have said of Americans that we always do the right thing, after we have exhausted all the other possibilities.

It is time for our political leaders to stand up for the health of the American people and implement a nonprofit, single-payer national health insurance system.

In part I blame news media for not presenting anything approaching a balanced, fact-based debate on health care. We get only the Right’s POV and more of the Right’s POV. I think if the American people understood the facts, we’d have national health care already.

11 thoughts on “Marketing Health Care

  1. Open enrollment Medicare for all is a no brainer. Preferably without a premium, and let private health care providers code share.

  2. One hospital in Chicago’s southwest suburbs just announced that it’s closing. It had been a respected and active cardiac care center, but it’s uninsured/underinsured patient population was just too high. The Catholic organization that owns the hospital couldn’t sell it or even give it away. Other hospitals in the area will be absorbing the overflow of those patients into their already overcrowded emergency rooms, leading to who knows what results.

    Of course, if you look at the comments on the newspaper’s website the fault is all the “illegals” – very little awareness of the contribution of America’s broken health delivery system, very little self-awareness of just how lucky those with a good paying job with good health benefits are. Those folks, of course, are smugly asserting that people who can’t pay for their health care are lazy and undeserving. Pretty sad.

  3. If nothing else, this is the ideal area where the two Dems can say what they are saying about health care. And, then, when elected, take the dick cheney attitude–we don’t have to let what we said in the campaign dictate what we do.

  4. I can’t find a definition of ‘market forces.’ Is there one? Sounds like some kind of perpetual-motion machine – runs itself, except that it doesn’t run at all.

  5. Something not even mentioned in all this is the rural places with dwindling populations and increased competition from urban hospitals. These are in the worst shape of all of them. The sooner we figure out there is not free market fairy with a magic wand that flies around correcting wrongs the sooner we can get on with making a more just and equitable society.

  6. hi maha,
    hate to write with a complaint, but i know you well enough to think that your words were not well-chosen. i have terminal colorectal cancer. 3 years ago, i was told i had 12-18 months. i’m still here.

    as fucked up as i think things are, and i am way radical, i’ve still got to tell you, 4.3 months more of life sound utterly delicious.

    peace and love, bruce in oz.

  7. Primary care shortages, educational shortfalls; worthwhile subjects, true, but they pale in comparison to the need for better understanding of how big is the immense WASTE of the present system. As a businessman, I was staggererd to learn just how big it is, and also how ignorant we all are of its magnitude.

    The other day the NY Times devoted some 20 column inches to the awfulness of earmarks, and how they cost $35 per person per year, much (but not all) of it wasted. Suppose the waste is $20; that’s one column inch per $ of waste. The newshole is about 1/3 the paper; so to produce proportionaltely the same coverage for the $1,000 per year per person of waste imposed by the overhead attributable to the insurance companies, the NYT would have to print 1000 column inches in the newshole. That would be a 30 page section of the newspaper, devoted to the $300+ billion of waste the present system pours down the drain every year.

    For more, see

  8. Re: the market not providing the things we need

    Nod. The idea behind an Adam Smith based utopia is that there’s unlimited capital and unlimited entrepreneurial ability. If there’s a two cents per dose profit to be made on anti-malarial meds, someone is going to chase down that profit. Why not? It’s money, right? And millions of folks suffer from malaria, right? So two cents a dose could add up to real money. And did I mention that it’s two cents a dose *profit*?

    But there’s only so much capital, and only so many resources, so the money will go somewhere else, where it can make a bigger profit.

    On a personal level, this is much more obvious. If the up front costs are essentially the same, which will you pick? A job as a lower paid GP or as a higher paid specialist? (A specialist might graduate with higher loan totals, but I’m guessing s/he also walks away with at least a proportionately higher salary.)

  9. I recently made an appointment for a medical with my Doctor in Chatham-Kent, Ontario. I was able to make an appointment within 3 weeks. My Doctor has 3200 patients. His practice is closed but he occasionally opens it up to new patients. I am lucky because 40% of the population in my area do not have a primary care giver. They go to the emergency room if they get sick. Ontario is also recruiting foreign medical school graduates and also pairing up nurse practitioners with primary care doctors to take some of the patient load. The problem is no one wants to be a Family Doctor. Each municipality has to recruit new doctors on a constant basis. I’ve been in Florida for a couple of months and my American freinds are complaining about having to wait for a physical longer than I had to wait at home. From reading the local newspaper and talking to people here what strikes me about health care in Florida is how routine it is to be denied coverage by the insurance companies. Also even if you have have insurance there are waiting lists. We have horror stories back home but it is usually about a high tech life saving procedure that isn’t covered…the patient has to go to the States for treatment (I think we should have the option of paying for high tech in Ontario if that is what we want). The other horror stories involve not having access to family doctor. In Ontario if you need to see a specialist the wait is longer here in Florida. Back home the primary care provider provides some level of triage and refers the patient on a more urgent basis if that is required (I’m talking from experience here).Those who can wait are required to wait longer. I get the sense here in Florida that the business case for the “Medical Industrial Complex” is very dependent on denying care to ensure profits are maximized by only providing coverage to healthy folks. What a sweet deal! If you’re sick and do not have insurance you get shuffled off to the emergency room and hope they don’t tum you away. I get the sense that many people with no coverage do not bother and get no treatment as a result. What a disgrace. While Canada’s system definitely has it’s faults I think on the whole it is better than here in Florida simply because we’re not tossing anybody under the bus. I believe our system could be improved if we adopted something similar to France (mix of private/public). Perhaps that would work here in the States as well and could be self financed by forcing the insurance companies to take a hike. I think that Paul Krugman has it exactly right in regard to solutions to the health care crisis here in the USA. Hopefully Barak is paying attention.

  10. matt — You don’t understand the problems and the issues, including the difference between “single payer” and “universal health care.” Although to be fair, many on the Left don’t, either. Based on the examples of other countries, what works best is a mixed public and private system, like the French health care system, rather than pure single payer. However, as long as the health insurance industry is allowed to determine who lives and who dies (you can that “freedom”?) there will be no meaningful reform.

Comments are closed.