How the Election Could Impact Physicians

When John McCain and Barack Obama talk about their respective plans for healthcare reform, they understandably focus almost exclusively on how patients will be affected. But what about physicians and other providers within the healthcare system?

Now that healthcare is becoming a more prominent issue in the presidential campaign, that's a question that needs to be answered.

The Senators' approaches are steered in part by their respective philosophies—at Tuesday night's presidential debate, Obama said healthcare "should be a right for every American," whereas McCain said it was a responsibility, but stopped short of calling it a right.

You can get into the nitty-gritty details of their proposals about issues like tort reform and EMR adoption on the Obama and McCain Web sites. But for now, let's consider how their two overarching approaches might impact how physicians practice.

Senator Obama's plan
In short, Obama wants to expand coverage through a combination of public and private options, including a new National Health Insurance Exchange that will offer insurance modeled on the Federal Employees Health Benefits Program. Although the plan is not universal, he would mandate coverage for children up to age 25.

How it might help physicians: Obama's approach could alleviate some of the burdens associated with uncompensated care by covering up to three-quarters of the current uninsured population, says Jonathan Oberlander, PhD, associate professor of health policy and politics at the University of North Carolina at Chapel Hill.

Uninsured patients who currently rely on the ED as their primary source of care would have better access to the preventive and primary care services that come with full health insurance. That could also boost practice bottom lines. Doctors who provide a lot of uncompensated care may start seeing revenue come in from patients who couldn't pay before, Oberlander says.

How it might hurt: We already have a pseudo-bellwether in Massachusetts. Although Obama's proposal doesn't mandate coverage for everyone, as the Massachusetts model does, the challenges may be similar.

The problem is a lack of resources to meet an increase in demand. Twelve of 18 specialties in Massachusetts are experiencing shortages, according to a work force study released this week by the Massachusetts Medical Society. Although there are a lot of factors involved—many of which are being seen across the country—the influx of insured patients has strained the understaffed healthcare system. Safety-net hospitals are struggling, and the average wait to see an internist is 50 days.

Obama offered "loan repayment, adequate reimbursement, grants for training curricula, and infrastructure support to improve working conditions" as strategies to boost the number of primary care physicians in a response to a questionnaire from the American Academy of Family Physicians.

The question, however, is timing. Insurance coverage can be expanded relatively quickly, but it will take years to train enough primary care doctors. Will the current work force be able to handle the higher patient demand in the meantime? Will costs continue to skyrocket? A recent analysis in Health Affairs criticizes the Obama plan for failing to address the economic incentives that drive healthcare spending.

Senator McCain's plan
The McCain plan is in many ways more unique and a bigger change than Obama's. It seeks to shift health insurance purchasing from the employer to the individual by offering individuals a $2,500 tax credit ($5,000 for families) to purchase private health insurance. It will also adjust regulations to allow people to shop for insurance across state lines.

How it might help physicians: McCain wants to "unleash the market and promote competition in the healthcare system," Oberlander says. Physician groups that have made strides toward transparency and catering to healthcare consumerism will continue to do well.

McCain's plan could also expand coverage by making private insurance more accessible, although that has been highly debated.

How it might hurt: One source of that debate was the same issue of Health Affairs that critiqued Obama's plan. McCain may offset his tax cuts by eliminating "the current tax exclusion of employer payments for health coverage," which the authors argue could push individuals away from employer-based insurance and expand, rather than decrease, the number of uninsured within five years.

The bigger question that has yet to be answered is how McCain's promise to allow insurance shopping across state lines would affect physician-payer relationships, as well as the overall system.

"Of course it's OK to go across state lines because in Arizona they may offer a better plan that suits you best than it does here in Tennessee," McCain said during Tuesday's debate.

But how will that affect the physician group in Tennessee whose patient population relies on one or more of the major payers in the state? Will physicians now have to negotiate contracts across state lines with dozens of companies all across the country? Will insurers adjust reimbursement rates to reflect variable costs in different locations? Will disputes and regulations be handled by the physician's state, the insurer's state, or the federal government?

"I would project that the number of doctors taking Tylenol would increase because the administrative headaches have to go up," says Oberlander. "There's already the madness of dealing with the insurers in your own state. Now you're going to take on other states' madness?"

The bottom line
Each of the plans raises questions, and neither completely addresses problems of coverage and costs, both of which are crucial elements to healthcare reform.

But from what I can gather, physicians tend to agree with the Senator from Illinois. A group called Doctors for Obama claims it is the largest number of physicians to ever endorse a candidate for political office, and as of this writing 7,369 doctors and medical students have signed their letter supporting Obama's plan.

But that's all the information I have—political pollsters unfortunately don't single out physicians. What do you think? Do you support one plan over the other, or do you think both are flawed? send me an email with your thoughts.