In Massachusetts, Universal Coverage Strains Care

Once they discover that she is Dr. Kate, the supplicants line up to approach at dinner parties and ballet recitals. Surely, they suggest to Dr. Katherine J. Atkinson, a family physician here, she might find a way to move them up her lengthy waiting list for new patients.

Those fortunate enough to make it soon learn they face another long wait: Dr. Atkinson’s next opening for a physical is not until early May — of 2009.

Now in Massachusetts, in an unintended consequence of universal coverage, the imbalance is being exacerbated by the state’s new law requiring residents to have health insurance.

“It’s a recipe for disaster,” Dr. Sereno said. “It’s great that people have access to health care, but now we’ve got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care.”

Here in Massachusetts, legislative leaders have proposed bills to forgive medical school debt for those willing to practice primary care in underserved areas; a similar law, worth $15.6 million, passed in New York this week. Massachusetts also recently authorized the opening of clinics in drug stores, hoping to relieve the pressure.

Dr. Atkinson, 45, said she paid herself a salary of $110,000 last year. Her insurance reimbursements often do not cover her costs, she said.

“I calculated that every time I have a Medicare patient it’s like handing them a $20 bill when they leave,” she said. “I never went into medicine to get rich, but I never expected to feel as disrespected as I feel. Where is the incentive for a practice like ours?”

I did read the article as well as several others (my Posts #10 and #11). This article does not exist in a vacuum to determine what did and is happening.

In Massachusetts that shortage of doctors and health care providers exists - you said it does and that will be a granted. However, in another the article states; "Nonetheless, the overall structure of private health insurance and the payment and delivery of medical care will remain intact, and costs will relentlessly increase" (in Post #11). Reading "...delivery remains in tact ...", makes me wonder ... was the shortage of doctors and health care providers the case in Massachusetts prior to the Legislature passing this health care reform? I don't know.

Also, in Massachusetts the 'Connector Board' opened up the statute language by their interpretation of it: "The Connector Board also bowed to pressure and reduced the monthly premiums on the subsidized-but-not-entirely-free healthcare plans. This will increase the program’s costs by $13 million"(in Post #11). Also cited rising cost, without this tampering, in paragraph above with the article (from Post #10).

Many people not getting health care is as true for any State in the Union, that includes Massachusetts. People in Massachusetts's "must carry a minimum level of health insurance, a requirement that will be enforced through the state tax return. Coverage may be through an employer, Medicaid, Medicare." (see Post #10) Is it a check box on your state tax return?

Coverage through and employer for the employee, in many plans has no cost to the employee, it is a cost of doing business for an employer and not an employee choice. Choice comes in when there is a cost to the employee in covering a spouse or family. So if you employer gives you coverage - you got it. Same with Medicare - you got it. Do these people get more through other means or only the minimum required by the statute? If they do they do, do have to report it, with additional check boxes on state tax return? Choices for some, yes. Any way, the main point is who is left without coverage as defined by the statute? Only those the law was intended to cover. Question, who is being covered?

The shortage of doctors, if existing before the passage of the law, definetly complected its implementation. Would not matter if have a person is covered or not covered. Doctor shortage would affect everyone. However, couple this shortage with the Connector Board opening up the pool of people covered and lowering the cost is exactly what placed in into a deficit position. I don't believe the Legislature passed the law if the Revenue Impact statement (if Massachusetts has such a thing) showed that it would cost the State exorbitantly in their tax revenues which actually fund State government. In this instance, in Massachusetts, it did matter who was in charge and those policy decision they made. In this case the statute was not the culprit, the sole culprit, rather those placed into positions of responsibility to see to the implementation and administration of some very complected problem(s). As well as the fact that any complications existing were not alleviated (by the Legislature or some State Agency) before it was passed.

This same health care environment exists in every State in that it is legislatively controlled or mandated in one way form or another. Massachusetts is peculiar in how the mandate is made by the Legislature. The form or vehicle the Legislature creates makes a difference ... but I don't believe it makes Massachusetts so unique that it must be treated in a void from other States. High costs and deficits are a result of Legislative mandate in all States and the those made by the Feds in providing health care. If policy costs are higher in one State than another, that is a different problem.

Shortages of doctors do exist in many places, I do not deny that. As I said I haven't seen that in Austin ... or the hue and cry isn't on the news coverage.

For you in Massachusetts maybe you need a 'new' Legislature with 'new' ideas to write a 'new' statute to replace the current one. Maybe the Legislature needs to get 'new' Connector Board Administrator and members, but I believe that's the Governors prerogatives. Will that happen, I don't know. Short of that Massachusetts citizens will continue to pay the deficits.

Massachusetts isn't unique. You can not address one issue and only one issue. The interrelationships with other issues must also be handled as they impact each other. I.E., the shortage of doctors/health care professionals, number of patients with own coverage, number of patents without coverage or mandated coverage, cost (premium) of insurance, benefits of insurance plan (purchased or mandated), State and Federal mandates ... and the list goes on. As for doctors, I don't believe Henry Ford's assembly line philosophy for making cars is valid for medical care ... but its gotten that way.

In Massachusetts that shortage of doctors and health care providers exists - you said it does and that will be a granted.

I didn't say that - the article did. I even posted the pertinent excerpt from the article. It wasn't me that said there was a shortage - it was the New York Times.

makes me wonder ... was the shortage of doctors and health care providers the case in Massachusetts prior to the Legislature passing this health care reform? I don't know.

The article answers your question...

The state ranks well above the national average in the per capita supply of all doctors and of primary care physicians.

You said:

However, couple this shortage with the Connector Board opening up the pool of people covered and lowering the cost is exactly what placed in into a deficit position...In this instance, in Massachusetts, it did matter who was in charge and those policy decision they made. In this case the statute was not the culprit, the sole culprit, rather those placed into positions of responsibility to see to the implementation and administration of some very complected problem(s).

First of all, you are using the word "complected" when I think you intend to say "complicated". "Complected" refers to a persons facial complexion, whereas "complicated" refers to something that is difficult to understand.

Secondly, the 'Connector Board' did not "open up the pool of people covered" as you say. From your post 11:

Interestingly, the Commonwealth Health Insurance Connector Authority, the bureaucrats in charge of implementing the plan, decided that the universal individual mandate does not apply to everyone, but rather only those who can afford the premiums. Therefore, nearly one in five of the currently uninsured will be exempt from the law.

As you can see, they exempted many people from the insurance requirement. If the law were fully implemented, things would be even worse. So it is the statute itself that is the causing the problem, not the administrators or their policy decisions. There was no doctor shortage before the law was passed - the Massachusetts law is fully to blame for the shortage. It doesn't matter who the administrators in charge are in this case.

First, I apologize for the spelling error.

shortage ... the article is dated 5 April 2008. So the shortage exists today. If there is now any shortage (as discussed in the NYT article) of doctors it has to be due to their personal choice, limiting patients for many different reason, retirement, not wanting to practice in Massachusetts, not enough medical school students or other. The article does not explain fully.

If the article says "The state ranks well above the national average in the per capita supply of all doctors and of primary care physicians." ... then evidently there's no problem. No shortage. Enough doctors for all the citizens. We can't have it both ways. The point raised was: this bill was passed in April 2006 ... was there a shortage prior to passage in April 2006? You don't know and I don't know. That is a major complication and hurdle to overcome if it were in fact true. If not then other problems exist and complicate the implementation and administration. The NYT article only claims an imbalance because patients want to take care of 'long differed care'. A choice the patient or prospective patient made in the past and doctors must cope with now.

Using the NYT article only 340,00 of 600,000 uninsured have gotten coverage. That's a huge amount. I can only think the Legislature figured on 600,000 getting in a price "X" or did the data they used showed substantially less uninsured in the State. I don't have access to their data they had for deliberation on passing the bill, usually received in hearings, to determine their intent .

The problem at this point appears to be the Connector Board. Since the Connector Board in their various interpretations of the statute changed the meaning and possibly the intent of the statute. Specifically, in their determination of who is covered, they left people out (I misread that and I apologize). The Connector Board by this action actually caused a 'shrinking the pool' of recipients and one could infer a cost savings. The statute didn't leave people out, it appears clear in its wording of exactly who the Legislature intended to be covered by stating what the minimum level of health insurance was deemed to be.

If (1) there are less people covered than envisioned by the Legislature and the statute they wrote, and (2) the costs to the State are higher as a direct outcome of the Connector Board's decision to lower the price paid by those enrolled ... then The Connector Board in cutting the pool, thereby cutting it's income ... because of outside pressure. Result in budget deficits for the State.

Maybe it was the Democratically controlled Legislatures' intent that the statute be interpreted and administered in just this way. Then again, maybe not. The Legislature hasn't stepped in, so my guess is that they are okay with the decisions of the Connector Board.

Many laws shouldn't be written to begin with, however when they are there is an expectation that they will be administered and carried out by the appropriate authority. That authority bears the responsibility to administer them for the good of the people (or face some type of malfeasance charges) or go back to the Legislature and argue for their repeal. This admittedly does not occur to often and definetly not in this case.

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