Is it a bug or a feature?
That depends on how you feel about big bureaucratic corporations taking over American health care, but the New York Times reports that the controversial health care reform act has accelerated the destruction of small medical practices at the expense of large firms. And if the Times is right, these are part of some fundamental changes in the American health care system that no Supreme Court decision can undo:
From Colorado to Maryland, hospitals are scrambling to buy hospitals. Doctors are leaving small private practices. Large insurance companies are becoming more dominant as smaller ones disappear because they cannot stay competitive. States are simplifying decades of Medicaid rules and planning new ways for poor and rich alike to buy policies more easily. [...]
Other changes influenced by the legislation may leave some patients and doctors lost in the new land of giants. As medicine moves from a cottage industry to one dominated by large organizations, some patients with insurance will probably find their choices more limited. But their care may be better coordinated, as hospitals, doctors and even insurers join to streamline services.
“The system is transforming itself,” said Charles N. Kahn III, president of the Federation of American Hospitals. “But the success of these changes depends a lot on whether there is sufficient funding.”
Is this what the social engineers who redesigned the American health care system really wanted to do? Is big better in health care, and is bigger still better still?
If the Times is right, so far the principal effect of the plan has been to accelerate the decline of family doctors and small medical practices in favor of larger, bureaucratic health care providers along the lines of HMOs.
This strikes Via Meadia as a step in the wrong direction. Health care reform needs to encourage innovation and flexibility. The rise of enormous, super-empowered HMOs closely tied to government regulations suggests we are headed further in the direction of building a corporatist, medico-industrial complex whose powerful lobbies will fight reforms, abuse monopoly powers and further congeal the American health care system into an unmanageable and unaffordable form that will undermine living standards while providing ever-less-satisfactory care.
Further accelerating our current trend of replacing a diverse and varied system with a few monolithic medical bureaucracies is not, on the whole, a positive development. Ironically, the new trend toward giantism in health care is coming just as breakthroughs in IT make it easier to synthesize the advantages of large organizations with the flexibility of smaller ones. We should for example be using IT to combine large company benefits (like easily available medical records that all a patients’ doctors can easily access) with the advantages of flexible, personal small firms and medical practices. As the blue model slowly implodes, we should be looking for ways to encourage innovation and entrepreneurship in the medical industry — but we seem to be going the other way, fast.
Was that the plan all the time, or is it a side effect that the health law’s framers didn’t fully anticipate or understand? Either way, it doesn’t seem good.
Other features of the program — making it easier for young adults to stay on their parents’ plans — are more beneficial, but there is that sneaking suspicion one acquires late in life that there are no free lunches and that all of these benefits have to be paid for somehow, by somebody, at some point in time. How much does it cost? Who will pay? When does the bill come due? Almost two years after the health care plan passed Congress, Via Meadia is under the impression that neither Congress, nor the administration, nor the public at large really knows all that much about what we have done.