Observations About the 2022 Mid-Term Elections
As a person who majored in political science and has been engaged actively in public
Many people have wondered why I, who have been passionate about universal access to health care, would have been, at best, lukewarm about both the recently enacted Patient Protection and Affordable Care Act (the name of the national health insurance reform legislation) and the earlier Massachusetts health insurance reform legislation.
Supporters of these pieces of legislation consider them a necessary first step toward longer-term health care system transformation. Many point to a September 2009 Harvard Medical School study which estimated that lack of health insurance cost 45,000 American lives each year. If this admittedly imperfect legislation saved those 45,000 lives, how could it be negative? Moreover, how could anyone who cares about human life not enthusiastically support this legislation?
The flaw in their thinking is that they assume that the legislation has no other consequences that might result in reduced health care access, and, therefore, a potentially greater loss of lives for other reasons.
People fail to seek out health care for many reasons, of which the fear of financial ruin is only one:
While supporters of these pieces of legislation can envision the improved access health insurance creates, they cannot easily comprehend the reduced access the greater demand-supply imbalance creates.
If 32 million Americans get added to the ranks of those seeking health care and we do not change the number of health care professionals, that means that physicians have to do one or more of five things to manage the increased workload, four of which definitely worsen the overall quality of system health care:
The fifth tactic is to delegate more tasks to nurses and nurse-practitioners, which would not degrade care quality or access, but there is a shortage of these professionals as well, so it is not clear that this is a viable alternative for many physicians.
In Massachusetts, it appears that most physicians are either delaying non-emergency appointments or dropping Medicaid patients altogether. Why is this significant?
We need an objective study by the Harvard Medical or a similarly reputable research organization that analyzes the behavioral responses of physicians and patients to an increased patient load, and that determines the health effects from those behavioral responses. Will patients who would have been saved through their current access to health care now see that access decline so much that they either delay or skip needed preventive screenings and end up dying because of that? I believe this is likely, but, obviously do not know whether it will end up being more or fewer than the arguable 45,000 lives that could be saved through giving people access to health insurance.
That is why I felt that the most compelling priority for lawmakers was to address the imbalances between health care demand and health care availability, not to do a massive health insurance expansion program and leave the health care availability problem largely untouched.
Many pieces of the federal legislation attempt to increase the supply of physicians and nurses, particularly in under-served areas. However, many major obstacles to health care capacity result from a variety of state and local laws, regulations, and practices that this legislation did not touch, such as Connecticut’s certificate of need process, which is often used as a weapon to protect small, local physician practices against perceived competition from small retail clinics.
I do not advocate centralizing the health care system, but the real obstacles to health care access, which is what matters more than health insurance access, relate to many policies and practices yet to be addressed.
It took much political will for the President and the Congress to enact this well-intentioned piece of legislation. I just wish they had staged the insurance expansion more in parallel with health care capacity expansion, rather than jumping out ahead with insurance and leaving the health care piece to be addressed more slowly.