Bush, the Oil Capitalist, Becomes a Monarch on Health Care

Dear President Bush,

This morning I noted the decree you issued yesterday to Congress to enact your White House proposals aimed at reigning in health care costs. Are you aware that one of the causes of hospital cost increases is covering the care for uninsured patients? During the time health insurance premiums rose 73%, our country added over 6 million uninsureds to the rolls, now approaching 50 million people.

You call your proposals “common sense”, yet there are several glaring inconsistencies when compared to your hands off oil & gas strategy. Both markets have an imbalance of supply and demand, i.e. demand exceeds supply. In energy you propose long term incentives to increase supply, yet there are no supply components to your health care strategy.

There is considerable risk in your ignoring physician and hospital supply. Both have long lead times to impact production, a decade for physicians and 2-3 years for a hospital assuming trained staff can be recruited or trained. Flu pandemic preparations cite little to no “surge capacity” in the current health care system. The CDC’s plan says a flu pandemic would place a huge burden on the U.S. health care system. As “huge medical burden” equals “overwhelming economic demand”, this adds to my confusion as to why your health care solutions ignore the supply side of the marketplace.

You have stated that physicians are in short supply, even citing how 1500 counties have no OB/GYN doctor. Of course, that is a scare statistic, otherwise you would have a plan to train and recruit 1,500 obstetricians in your “common sense” plans. As it is not there, this is a scarecrow, easily knocked down.

The risk to physician supply is the aging of the doctor workforce. Physicians are considerable older as a group today than they were several decades ago. Assuming current retirement rates, American medical colleges are projecting a 25,000 to 238,000 physician shortage by 2020. Should doctors get frustrated and quit or reduce their practice panels like those 1500 OB’s you cite, what happens to supply? It shrinks tighter than your sphincter during a Steven Colbert’s Presidential roast.

Have you put that out of your mind? Steven served as the headline act at the White House Correspondents Association dinner. Funny how clips of you and your comedic twin splashed the screens, but Mr. Colbert’s far right wing parody fell flat on a stunned audience. The modern day court jester turned his act on the King! No one could believe what they were hearing, full out belly laugh humor stifled into no breath whatsoever. You must be quite the dark force to engineer a comedic black hole.

Whether the appropriate analogy for tight physician supply is your sphincter or the audience’s chest muscles is irrelevant. If older doctors throw their hands up in disgust and retire en masse, prices will go through the roof. Health care will look like gas, water, and plywood after a hurricane.

Why do I believe your “common sense” proposals will drive doctors to retire? Doctors in West Texas are already frustrated with the non system, especially the high level of uninsured in San Angelo, as nearly 30% of the population is without health insurance. Most doctors I know don’t accept Medicaid, except those scarce as hen’s teeth OB/GYN’s. It seems Medicaid pays pretty well for births.

In their multi-specialty group practices, doctors have little exposure to the uninsured. The business offices screen them out. Those who can afford the $100 deposit get the office visit, those who can’t go to the community health center, the hospital ER, or go without care. Getting “marked up”, i.e. having to offer free physician care through their ER call rotations, is another source of frustration. As you note in you Medicare prescription drug cheerleading sessions, care delayed often results in much more expensive treatment later. Many of the uninsureds presenting to ER’s fulfill this prophesy.

What galls my friends and relatives even more is their declining income. While still robust, physician income has fallen each of the last several years. Doctors ask themselves, why am I working harder for less money? What happens when your “common sense” proposals are enacted and doctor income falls further?

Health savings accounts must be paired with high deductible health plans. This means the person with coverage must pay the first $1,050 of their health care costs before insurance kicks in. The deductible is higher for family coverage. These high deductible plans mean people are self insuring the first $1,050 to $2,100 of their annual health care costs. Some will fund their health savings account with tax free money, others will not. Studies to date do not show high numbers of eligible people funding their HSA’s. One released last fall shows only 1 in 10 eligible worker funding their HSA.

When HDHP patients show up at the doctor’s office, they look like the uninsured until they meet their annual deductible. While some plans cover primary care doctor visits or a portion thereof, not all do so. Many high deductible patients will get the same business office treatment as the uninsured. Those able to pay the $100 deposit will be seen. The rest will have to figure out something else, much like the uninsured currently do.

Studies show both people covered under HDHP’s and those without health insurance delay needed care, don’t get recommend check ups or health screenings. Forty one percent of uninsured adults skipped medical care because of costs in the past year vs. 9% of insured patients. Over half of uninsured patients, 57%, have no primary care physician vs. 16% of people with insurance.

You said “my administration is determined to do something about it”, yet you ignore a major cause of rising health care costs, caring for the uninsured. What you are doing will only make matters worse as it greases the skids for employers to add legions of under-insureds to the already scandalous numbers of uninsured in the U.S.

The stage is set for a debacle. With supply already short, safety net hospitals are at risk from growing uncollectible accounts previously covered by insurance. With physician capacity already constrained and projected to grow worse without mass retirements, patients are at risk for even having a “doctor-patient relationship”. Even a slight increase in retirements will have severe repercussions on physician access and availability.

Just as the market is optimal for integrated oil companies, for profit health care stands to benefit from your proposals. Insurance companies stand to benefit from Medicare and Medicaid “modernization”, a euphemism for contracting out the insurance function to the private sector. For profit hospitals have the attentive ear of the White House and Congress. They have found a way in the past to manage their uninsured patient loads and I trust they will continue to do so.

People with good insurance and financial resources will enjoy premium access to health care. The challenges will amplify for the uninsured, those on Medicaid and the low wage worker with a high deductible health plan. Both are growing rapidly on your shift. A recent study indicated an almost 50% increase in the number of moderate to middle income uninsureds in just 4 years.