Government Leverage V. Physician Leverage

As Archimedes said, “Give me a place to stand, and I will move the earth.”

Well, we know where the government stands, on ObamaCare. For 5 years, Obama has been saying will lower costs, allow you to keep your doctor and health plan, and improve the quality of care. The problem is ObamaCare has achieved none of these lofty goals, not yet anyway. Accountable Care Organizations, ObamaCare’s favorite tool for lowering costs, has largely failed to save money for government. The lever is moving left, towards more Medicaid programs, but it is also moving right, towards more market-based solutions.

That vexing question remains: Is Government the solution or the problem?

So far, the public is unconvinced government is the solution. Today’s Real Clear Politics average of national polls indicates 7.3% more Americans disapprove than approve of the health law.

But, as president, Obama has leverage. He has the law in hand, he has the Supreme Court on his side, he has the bully pulpit , he has roughly 40% of Americans dependent on Medicare and Medicaid, and he has the national media on his side, which the public believes is “ biased “ towards the progressive agenda.

And, as Cervantes observed in Don Quixote, “ A bird in the hand is worth two in the bush.” In the present political situation, the bird in hand is a law that has passed and affirmed by the Supreme Court, and two in the bush is GOP opposition and the upcoming 2016 elections, which could be captured by a Bush in the bush.

To these birds, I might add a another bird – growing physician opposition to regulations and expenses and difficulties of remaining in small private practice. Sixty percent of doctors remain in small private practices. But their numbers are dwindling, as they retire early, join larger groups, or become employees for hospitals. Despite increasing pressures to become ACA serfs, physicians have a leverage - increasing numbers are not accepting Medicare, Medicaid, or health exchange patients., and more are entering direct cash practices.

No one knows the physician rate of non-acceptance or delays in seeing patients in federal programs, but it is believed to be about 40% to 50% for Medicaid, 5% to 10% for Medicare, and 25% for health exchange patients. Part of the gap of physician resistance is being filled by increased efficiency through use of nurse practitioners and physician assistants, but many patients and physicians still prefer to interact directly

Direct cash practices, which have lower costs than government or private 3rd party affiliated practices and far less overhead, have become more attractive to the public as health exchange and private insurers and employers have turned to high deductible plans, which require out-of-pocket expenditures up to the level of the deductible.

What does it all mean? Probably a 2 tier system, with half the population dependent on government programs and half the people and physicians turning to market-based care.