By Scott W. Atlas, MD
While today’s headlines focus on the horrendous technical failures of Obamacare’s insurance websites, and analysis remains fixated on insider political fights about the law, it will take years after this initial implementation for its real legacy to become visible. Millions of Americans will lose their current insurance and with that the access to their choice of doctors and hospitals. Meanwhile, completely lost amidst the contentious debate about the law is the fact that medical care has undergone a revolution away from the primary care-dominated system of the past. Left virtually unmentioned is what might be the most misguided aspect of the law - Obama’s Affordable Care Act tries to undo the focus of modern medical care.
With 65-year-olds having a 50% longer life expectancy than in the mid-twentieth century while also living with less disability, the concept of being “old” needs to be reconsidered. Reformers must comprehend that advanced technology is fundamental to this improved survival and quality-of-life. Even government’s Health and Human Services and Centers for Disease Control acknowledge that “advances in medical technology . . . have improved our ability to monitor, prevent, diagnose, control and cure a growing number of health conditions” and “continue to transform the provision of health care and improve the length and quality of life.”
But it’s not just technology and drugs that form the core of modern medical care. Few patients with serious diseases today are managed without specialists. For seniors, visits to specialists have increased from 37% of visits two decades ago to 55% today. And that’s appropriate. Specialists are the doctors who have actual training to use the complex diagnostic tests and devices, state-of-the-art procedures and novel drugs of modern medicine. The pace of change and the need for specialists will only increase, especially given the growing population harboring America’s most important diseases - heart disease, cancer, and stroke – all of which require specialists. And the Association of American Medical Colleges already estimates a deficit of 64,800 non-primary care specialists by 2025.
Regardless of those facts, the Obama administration has been shifting resources and prioritization to generalist care at the expense of specialist care. The government’s Medicare Payment Advisory Commission already recommended substantial cuts to specialists — 16.7% over 3 years and then frozen, equivalent to a 50% decrease after the decade, considering inflation.
On top of that, the health reform legislation created the Independent Payment Advisory Board (IPAB) to reduce payments to doctors that will be almost impossible to overrule. Even Howard Dean, former Vermont Governor and Chair of the Democratic National Committee, wrote: “The IPAB is essentially a health-care rationing body … making medical decisions without knowing the patients.” Likely to first target medical technology and imaging, the predictable loss of access is reminiscent of restrictions on specialist care in nationalized systems that cause unconscionable waits and scandalous outcomes. Obamacare further threatens specialist care with harsh taxes on medical devices, the tools that streamline diagnosis, ensure safer treatment and save lives.
Even with the focused pressure Obamacare brings on specialist care, the effort is still going to leave primary care access in a precarious situation. If the ACA meets its goal of adding 30 million insured by 2022 adding to an enormous increase in elderly Americans, the situation will become even more daunting. The same research that shows Obamacare creating a specialists shortage predicts the number of primary care doctors will fall short by more than 65,000.
An informed vision for the future would focus on modernizing primary care delivery and prioritizing specialists and technology. Retail clinics instead of overburdened ER’s, staffed by allied health professionals instead of MD’s, would broaden access for simple care while saving $800 million per year or more. To increase the supply of qualified doctors who are trained to use advanced technology and to ensure clinical innovation, we must keep attracting top students into medicine. Therefore, rein in malpractice lawsuits, streamline training when possible, and then add common sense — it would be destructive to cut salaries for those who we need the most and who have the most valuable and unique expertise. And let’s incentivize American technological innovation, not quash it, starting with an immediate repeal of Obamacare’s device tax and more simplified FDA processes.
Ignored by most policy discussions is this simple truth — the administration’s vision of a primary care driven health system is fantasy, relying on an obsolete and naïve understanding of medical care. The future of medicine is more technology with an even more central role in patient care, a scenario that requires doctors to be even more specialized. No federal law or committee can change that reality, and no political agenda should be allowed to block it.
Scott W. Atlas, MD is the David and Joan Traitel Senior Fellow at the Hoover Institution, Stanford University