Supply and demand

As we move forward with health-care policy, we face a shortage of primary care doctors, an essential part of an ultimate plan for universal health care

BRATTLEBORO — In Economics 101, we learned something about supply and demand.

When shortages exist for goods and services, or for specialized personnel - such as receptionists and doctors - waiting lines and times lengthen. Prices might rise for scarce resources.

In health care, patients with long waits might suffer. In federal programs, especially the Department of Veterans Affairs (VA), veterans groups will protest (appropriately), while opposing political groups attack with denouncements of government medicine. Investigations follow, with new legislation, executive orders, quick fixes, and even major overhauls.

This seems part of the recent scandal at the Phoenix VA, also documented at some other VAs. (Much VA care is exceptionally fine.) Fewer than half of our veterans are registered as VA patients; the rest have other insurance or lack it.

As for privately insured Americans, many also experience similar long waits and cancellations, plus high co-pays, denials, etc., and they often go through spells of underinsurance or no coverage.

Primary-care doctor shortages are widespread, and as a society we have barely addressed the issue. However, we are all feeling it. Shortages and other problems are not unique to government medicine at all. Our whole society is in this together.

Just imagine the United States as a happy democracy (with far fewer wars?) where we work, play, get born, get sick, and finally get buried.

Imagine, too, that we are surrounded by an impenetrable wall and border police, so that few cross over. How can institutions respond to shortages of trained personnel, as in primary care?

Not an easy task.

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Our country has not planned its health-care force to meet the growing demand. We can't rapidly increase the doctor supply (or the supply of physician's assistants and nurse practitioners).

If we're short on health professionals, institutions might offer incentives to attract them. Doing so can reduce the institutional shortage but exacerbate the primary-care national deficit.

Hiring doctors during scarce times does not change the severity of the national shortage, it just shifts it around. One might call it “robbing Peter to pay Paul.”

Another technique is to transfer patients from a doctor-shortage service to somewhere else.

Example: In the 1980s, a hospitalized veteran might be discharged to a community nursing home, funded by designated VA funds for three months, followed by private pay or maybe Medicaid eligibility.

The VA operates on an annual budget. Registered VA patients are often assisted by social workers to enroll in Medicare, an open-ended entitlement program. They are thus discharged from the VA (excluding service-connected issues). This is allowed, despite the doctor shortage.

The private sector might try this tactic, which one might call “giving to Peter what Paul discards” or “dumping syndrome.”

As a medical consultant for in-patient private geropsychiatry patients, I witnessed “dumping” of patients transferred from a general hospital with alleged major depression. A non-psychiatric cause of symptoms was sometimes readily found.

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The 2010 U.S. Census counts 308.7 million people, and includes 22.5 million veterans and 5.2 million Native Americans. The latter remain an especially disadvantaged group, with highly fragmented health care and doctor shortages.

Many organizations - federal, state, county, private, and community-based - increasingly try to provide more primary health care. Of our 850,000 practicing physicians, fewer than half work in primary care. (Foreign-born doctors provide one-fourth of our primary care.)

Primary-care teams now face the huge upsurge in citizens insured through the federal Affordable Care Act. Even with ACA's full implementation, millions will remain uninsured or underinsured under the present laws of the land.

A single-payer health-care system will theoretically insure all, providing we can achieve an adequate supply of our dedicated primary-care team. But without them, we can't cover everyone.

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