ObamaCare problems: Doctor shortage, honor system
July 27, 2013
Add between 1 million and 2 million persons to the patient load of California doctors. Do not open any new medical schools or import many foreign-trained doctors. It's a sure-fire way to create a doctor shortage — and just where California is headed right now.
That's probably the most severe problem the Patient Protection and Affordable Health Care Act, often called Obamacare, faces in California when it becomes fully active Jan. 1, but it's hardly the only one.
There are insurance companies refusing to write policies for some small businesses. And how about the fact that the federal government at least for the first year of the program will not demand any kind of proof that people actually qualify for subsidies designed to make health insurance affordable to almost everyone.
Instead, a kind of honor system may be in effect. "For income verification, for the first year …, we are providing exchanges with temporarily expanded discretion to accept an attestation of projected annual household income without further verification," says a rule officials just inserted into the Federal Register.
This applies to states like California that have their own insurance exchanges, although the Covered California exchange says it might still demand pay stubs or their equivalent from clients.
"That's always been our plan, but since verification is now not required, we're looking at our options," said spokesman Dana Howard.
Which means that rule could cost billions in fraud if some of the newly insured lie about their income and don't get caught.
But the impending doctor shortage could actually be life threatening, making it the most severe problem that Covered California might face next year.
Take the example of Orange County. California's second-largest county will see as many as 280,000 persons now without health insurance suddenly become eligible next year.
That includes new Medi-Cal patients previously ineligible because they were childless or had too high an income. A single adult can now get Medi-Cal with an income of 138 percent of the federal poverty level, or $15,856.
Most will probably go to clinics for their primary care. But will those clinics have the personnel to take care of them? In Orange County alone, a population almost as large as Fresno's will suddenly be entitled to care, but there will be virtually no new doctors.
That's one reason for the steady progress through the Legislature of several bills giving non-physicians more authority to perform some types of medical care.
These would let pharmacists, nurse practitioners, optometrists, physician assistants and nurse midwives perform some functions now reserved for medical doctors.
"Pharmacists are the most under-used of health professionals, considering their years of education and training," says Democratic state Sen. Ed Hernandez of West Covina, author of the most sweeping bills to let non-doctors perform more medical functions.
Many pharmacists no longer spend most of their time counting pills or filling medication bottles. Technicians and automated pill counters can do those things. Instead, many pharmacists now spend significant time counseling patients on possible drug interactions when one doctor writes a prescription without knowing what another has already written. Pharmacists also often ask patients about their ailments and advise which drugs might work best for them.
Hernandez's bills would let pharmacists prescribe birth control pills, vaccines and some other types of medication on their own.
He contends they already do a lot of that, de facto, but doubts remain. Would pharmacists, for example, know what vaccines are appropriate for organ transplant recipients?
The long-term answer to the physician shortage is to set up more medical schools and train more doctors. But since Medicare, Medi-Cal and other programs have gradually cut fees they pay, an M.D. degree may no longer be an automatic ticket to wealth, and medical schools could have trouble attracting the top students they traditionally have.
There's also the small matter of how long it takes to train a doctor — 10 years or more for some specialists. So it will be a while before the doctor shortage is overcome, and despite opposition from the California Medical Association and many physicians, this means somebody besides doctors will have to provide some of the care for the newly insured.
Like it or not, comfortable or not with non-physicians making some medical decisions, that's the coming reality.
Elias is author of the current book "The Burzynski Breakthrough: The Most Promising Cancer Treatment and the Government's Campaign to Squelch It," now available in an updated third edition. His email address is firstname.lastname@example.org.