2XL2100ZA: That depends on whether the light bulb has health insurance!

My wife has entered into the Obamacare fray on Facebook. The thread started with her disappointment on discovering that our mayor-elect had invited the “polarizing” Ben Carson to our fair city. Dr Carson, as you may or may not be aware, is a neurosurgeon who apparently is very technically skilled and, as it turns out, happens to be black. His personal beliefs have put him in the news recently. This is because he has gone around the country telling how his conservative Christian worldview (including views on homosexuality and evolution) has, in his view, allowed him to experience success. Our mayor-elect invited Dr Carson to tell his inspiring story at a fundraiser for a private, faith-based academy focused on helping poor, African-American children in one of the poorest cities (Prichard, 14th poorest city in the country) in one of the poorest states (Alabama) in the country. Dr Carson, since accepting the invitation, has made his views on health care for all citizens of our country pretty clear:

“I have to tell you, you know Obamacare is really, I think, the worst thing that has happened in this nation since slavery,” Carson said. “And it is slavery  in a way because it is making all of us subservient to the government.”

Carson, who is African American, went on to say that the administration’s push toward Obamacare is reminiscent to a push toward socialism.

“It was never about health care, it was about control,” Carson said. “That’s why when this administration took office it didn’t matter that the country was going off the cliff economically.  All forces were directed toward getting this legislation passed.

“Vladimir Lenin, one of the fathers of Socialism and Communism, said that socialized medicine is the keystone to the establishment of the socialist state,” he added.

So, as you might imagine, my wife’s initial concern, expressed to a Facebook group, about  our mayor-elect’s connecting himself with Dr. Carson has degenerated into an argument over health care as a right.

Given that Prichard, where the Academy resides, has 22,000 people, is 85% black, has a per capita income of $13,000, and has 0 physicians offices in the city limits, the free market doesn’t seem to have been serving them very well. I don’t want to get into a discussion of the reality that 1) someone has to pay for health care; 2) currently the money for caring for the poor being granted to the hospitals has left a city of 22.000 with no doctors; and 3) If the money follows the patient, as it does in Obamacare, isn’t that really the market at work?

Instead, I will respond to the proposition that doctors will simply refuse to accept lower rates from the new exchanges, which appeared in the thread. This is linked to the ongoing myth that “Doctors are leaving medicine in droves.” This was dealt with by The Incidental Economist several years back. Remember, the exchanges are an insurance product. Physicians can either choose to accept insurance or not. Medicare and Medicaid are also an insurance product, albeit with more strings attached. In the article they analyzed, 95% of primary care physicians were accepting new patients with 90% accepting new Medicare patients and 70% accepting new Medicaid and private insurance patients. This has been stable for several years. We physicians have a symbiotic relationship with insurance companies that is not likely to be severed soon.

Many people believe (or want to believe) that concierge practices are a way out of the physician-insurance nightmare. In these practices, physicians eschew all insurance and instead limit the number of patients they care for (typically 600 or so) and charge a retainer not covered by insurance (anywhere between $40 and $400 per month). The advantage to the patient is the doctor’s cell number and unfettered access. Ever wake up in the middle of the night with a nagging cramp? Husband not sympathetic? Call the doc… Advantages for the doctor are less administrative overhead (insurace filings pushed to the patient). Conrad Murray was the ultimate concierge doc, charging Michael Jackson $150,000 per month, but the price was a little steep for both of them. Mostly, when docs shift to concierge practice, 88% of their patients leave. Currently about 50 such practices exist in the country, so while many physicians see it as an out, it is likely a limited career path.

What do I think is going to happen? I believe that, assuming the markets don’t tank, physicians over 62 or so will likely retire. This is more because of the electronic health record requirements than Obama-Lenin-care, which I don’t see the government backing away from. I think that those folks coming out of residency will adjust just fine. I think a lot of people from ages 45-55 who have planned for an income that is unachievable in a health care environment that no longer exists need to read “Who Moved My Cheese.”