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A Doctor Mom's View of Proposed Health Care Reforms

By Jack M. Balkin

Posted by Dr. Julia Frank, Professor of Psychiatry, George Washington University

Even as a left wing physician, I agree with my medical colleagues that health care reform must address three factors simultaneously: health insurance, malpractice costs, and the cost of medical education. Many who read this blog may not realize that the average medical student enters residency with staggering debt, ranging from $110,000 for graduates of public medical schools to $350,000 for a substantial minority of students from private schools. These are loan principals that balloon astronomically as young doctors repay their debts over time. New doctors essentially enter their professional lives obligated for 30 years of payments for houses they can?t live in. Medical student debt pushes graduates into higher paying specialties, subverting a primary care system that might reduce overall costs by promoting preventive care and early detection. Their debt is coupled with daunting malpractice insurance premiums for physicians in many specialties ($80,000+ per year plus years of tail coverage for an obstetrician, for example). It is hardly surprising the medical profession has been backward in embracing any reform that would drastically change (or that they fear would change) doctors? incomes.

The New England Journal of Medicine (8/21/08) recently compared the health plans of the two presidential candidates. McCain is relying on free market forces to address the crisis, using a byzantine system of tax credits and rebates to encourage individuals to vet and buy policies, including a range of policies that are inadequate to cover many expenses. He would ?deregulate? the already inadequately regulated insurance market. Obama?s plan includes more thoughtful proposals for regulating aspects of insurance, including bargaining down the high costs of drugs, stopping excess payments to private plans that bill (or bilk) Medicare, creating a federal health insurance plan for those who cannot buy private insurance (covering not just the chronically ill, but also small business employees and self employed people), and direct regulation of insurance companies to prevent ?cherry picking??excluding people who are likely to have high health care costs due to established illness.

Neither candidate is likely to win the hearts and minds of the medical profession. McCain advocates malpractice ?reform? as a separate issue, and Obama doesn?t mention it. Neither addresses the issue of student debt or its effects on the costs of care and on students? choice of specialties. Malpractice reform is, moreover, a slippery term, since it can mean anything from capping damages in medical lawsuits to creating a system similar to workman?s compensation for dealing with the consequences of treatment related damage or disability (a much more common phenomenon than damage from a doctor?s negligence, incompetence or malice).

I am still rooting for Obama (well I would anyway). At least he advocates for planning and direct regulation (promising some level of fairness in how new limits will be applied), rather than expecting the average hockey mom (who makes most health care decisions for her family) to take an insufficient tax rebate and use it choose the health insurance plan that adequately covers her family, lowers her doctor?s malpractice costs, helps the doctor pay off medical school debt (and allows her child, should it survive to adulthood, to contemplate being able to afford a medical education). We need to elect policy makers who will make policies, rather than those who flatter and cajole us into thinking that we moms can do this for ourselves, from where we sit, in the minutes of free time we have left over from just keeping our day to day teams on the field and our family ships afloat.

Full post as published by Balkinization on September 17, 2008 (boomark / email).