Karl Smith is amazed by the New England Journal of Medicine study showing that medical specialists -- or, perhaps, their practice networks -- did not offer care to Medicaid patients when they called to seek care.
...some hospitals are claiming that Medicaid reimbursements are running below their marginal costs. That is, they would do better to leave a bed empty than fill it with a Medicaid patient. I find this maddening. Not for the usual moral implications sort of way. Just in the fact that I am faced with a business which cannot profitably perform this service at a reimbursement rates far, far, far above the median wage. There is nothing that can be done? Really? ...I can't hire a 16 year-old kid to haul around one of the blood pressure monitors, hook each patient up to it and then type the results into some old rusty laptop?... I don’t know how to see this as anything other than a serious supply side catastrophe. (emphasis added)
Let's get his rhetorical question out of the way first: No, you can't hire a 16 year old off the street. Why? Because medical care is really, really dangerous. Medical errors are often lethal, and the treatments required to treat serious illnesses can kill you even when they are done right.
Having said that, his point is well-taken. You run into conspiracies in restraint of trade excessive credentialing by provider guilds wherever you go in US medicine. Moreover, changing the health insurance system will not, by itself, achieve health care reform.
We also need to change front line delivery systems. One element of the new system will be better and cheaper primary care: perhaps nurse practitioners with little offices in big box grocery stores, able to securely connect to unified patient health records, able to give smart care with assistance of medical AI systems, and able to do smart triage to more expensive care through consultation with specialists via Skype. True health care reform is supplying good care to everyone at an affordable cost, and this will require fundamental changes in how healthcare systems are staffed and organized.