01/22/2013 - 05:43

Undermining Obamacare

Laura H. Kahn

Laura H. Kahn

A general internist who began her career in health care as a registered nurse, Kahn works on the research staff of Princeton University's ...

More

Now that President Barack Obama has been reelected, his Affordable Care Act, "Obamacare," will move forward, which is good news for the health, safety, and security of the United States. But setting up Obamacare and actually providing it are two different challenges. Both will be hard.

Setting up Obamacare. Expanding health insurance coverage to the uninsured might seem straight forward, but, unfortunately, it won't be. Some states are balking at setting up health insurance exchanges, preferring to leave the task to the federal government. The Obama administration has even had to extend the deadline for states to decide if they'll cooperate or not. As of January 4, 2013, 25 states have decided not to cooperate. Meanwhile, states that are planning to set up their own exchanges confront a myriad of options, including the type of exchange, the structure, and the governance oversight. This could be good or bad. Each state will serve as an experiment.

Access to health care is a national security issue. When people don't have insurance, they also don't seek out health care right away. That means that people sick with a deadly communicable disease could set off an outbreak if they delay seeking medical care. Such delays would needlessly worsen a potentially deadly epidemic, making it harder to contain. Expanding health insurance coverage to the millions of Americans who previously went without it -- increasing the likelihood that more people will seek early treatment -- is a critical step toward improving America's ability to detect and respond to such crises.

But that is just the first step. The second, harder step will be to actually provide medical care and drugs to millions of additional people.

Providing Obamacare: Physician shortages. Globally, there is a serious shortage of physicians, particularly primary care physicians, and it's expected to get worse in the coming years. The American Association of Medical Colleges estimates that, by 2015, there will be a shortage of more than 60,000 physicians in the United States. By 2025, the shortage could reach well over 100,000 physicians.

One reason for the shortage is that there just aren't enough medical schools and residency programs to meet the needs of a fast-growing aging population. It takes over a decade to train a physician -- from college to medical school to residencies, internships, and extra fellowships. Additionally, in general, primary care physicians aren't compensated as well as specialists, making the field less attractive to medical students, who often incur huge debts to attend medical school.

In the short term, physicians from other countries will continue to pour into the United States to practice. This isn't a new phenomenon. The United States has been dependent on foreign-trained physicians to meet its needs for years. The problem is, when doctors leave their home countries -- particularly poor developing countries -- to make more money in the United States, they leave behind nations without enough physicians to provide medical care for their own populations. And that jeopardizes global health. Epidemics begin locally and, if identified early, have a better chance of being contained. Without physicians on the front lines, deadly epidemics can spread.

Plus, even with foreign doctors working in the United States, there continues to be a dwindling number of primary care physicians. In an era of exploding medical knowledge and advanced technologies, being a generalist is proving to be very difficult. There are now so many clinical practice guidelines and algorithms for physicians to follow, the practice of medicine is becoming one big complicated flow-chart. The Medicare Improvements for Patients and Providers Act of 2008 asked the Institute of Medicine to evaluate all the measures and guidelines to ascertain which were worth following. What happened? The Institute of Medicine developed standards to follow the guidelines. No wonder no one wants to practice primary care.

David D. Norenberg, an internist practicing almost 40 years in Wisconsin, wrote a compelling essay in 2009 about the demise of primary care medicine: "[T]hese well-intentioned practice guidelines, initially meant as helpful suggestions … have been transformed by politicians, business leaders, and acquiescing assurance committees into the nemesis of primary care: one-size-fits-all medicine." Norenberg believes that "quality improvement" has become so oppressive that the only option for physicians is to focus on one organ system -- in other words, practice sub-specialty medicine. Nobody wants to pay primary care physicians to provide individual-based care.

One solution is to expand the number of nurse practitioners. They take less time to train, require less compensation, are often willing to practice in underserved areas, and provide basic health care. For people with uncomplicated health problems, they're a viable option. So far, only 16 states and Washington, DC, allow nurse practitioners complete practice independence. Predictably, physicians' organizations are opposed to this strategy.

Providing Obamacare: Drug shortages. If physician shortages weren't bad enough, there are also drug shortages. In 2011, 251 drugs were in short supply. The shortages have been largely due to manufacturing flaws, prompting the deficient factories to close -- and these are the manufacturers that the Food and Drug Administration inspects. We've seen what happens when manufacturers, such as the New England Compounding Center, don't get inspected: a deadly meningitis epidemic.

In late October 2011, President Obama issued an executive order that was supposed to address the growing drug-shortage crisis. The order instructed the FDA to broaden its reporting of potential shortages of prescription drugs, provide information to the Justice Department about possible cases of price gouging or collusion, and speed up reviews of applications to begin or adjust drug production. But even this step is considered modest, at best.

If a country can't ensure an adequate supply of critical drugs during normal times, then how is it supposed to provide them during a time of crisis? Simply providing a list of drugs in short supply doesn't cut it.

On June 15, 2012, a congressional report, "FDA's Contribution to the Drug Shortage Crisis," begins by stating, "The drug shortage crisis that took off in 2010 began shortly after Margaret Hamburg became FDA Commissioner." The report goes on to accuse the FDA of failing to ensure enforcement and compliance activities. The report also found that shortages of generic injectable medications were caused by changes in a provision in the 2003 Medicare Modernization Act, which lowered the prices of these drugs, causing the companies that produce them to lose money. The lost revenue reduced the companies' incentives to upgrade manufacturing capabilities. The companies producing these drugs thus dwindled, creating a supply bottleneck -- especially if they had manufacturing problems.

In other words: It all comes down to money.

The bottom line. Everybody wants quality, affordable health care with safe, effective drugs. The challenge will be to provide it to as many people as possible without bankrupting the nation. Let's hope Obamacare is a step in the right direction.