Richard L. Reece, MD

"We must dare to think 'unthinkable' thoughts. We must learn to explore all the options and possibilities that confront us in a complex and rapid changing world. We must learn to welcome and not to fear the voices of dissent. We must dare to think about 'unthinkable things' because when things become unthinkable, thinking stops and actions becomes mindless.


- Senator William Fulbright (1905-1995), speech before the Senate (March 17, 1964)

With Paul Ryan (R-Wisc.) as Mitt Romney’s selection for vice president, the pivot point of the presidential campaign may now depend on Medicare. No longer are Republicans defensive about Medicare; they are now on offense. The GOP is saying that Obamacare “raids” $716 billion (Congressional Budget Office estimate) from the Medicare trust fund and that their plan does not affect those 55 or over.

The dynamics of the Medicare debate have changed dramatically. With the Supreme Court decision and the sudden political visibility and viability of an alternative Medicare plan that arguably spares current and would-be seniors 10 years away from Medicare, Medicare joins the economy as a central campaign issue, and Obamacare slashes 40 percent from physician incomes.

If you believe physician surveys, some 30 percent to 50 percent of physicians are saying they will no longer be able to afford to accept new Medicare and Medicaid patients. A new e-survey of 650,000 physicians, conducted by Merritt Hawkins for the Physicians Foundation, with 14,500 responses, to be released in early September, affirms these estimates and gives more fodder for those who “think the unthinkable.”

Why the exodus? Because on average, Medicaid on average pays 56 percent of private care rates, and Medicare pays 81 percent of health plan rates, and Congress shows no appetite for fixing the SGR formula, which calls for 27 percent reductions in Medicare fees.

One “unthinkable" aspect of the Medicare debate is the likely exodus of hundreds of thousands of physicians from government programs. According to government estimates, 624,000 physicians are directly engaged in patient care. If you use the figures of 30 percent to 50 percent, 187,000 to 312,000 would cease seeing new Medicare and Medicaid patients. The patients now number 110,000. These numbers will increase by 30 million to 50 million in 2014 under Obamacare and with the addition of 10,000 to 12,000 new Medicare eligible baby boomers each day, which began in 2011.

Add to these figures Obamacare plans to “save” Medicare by reducing physician incomes by 40 percent, and Congress refuses to fix SGR, which cuts another 27 percent. and the government will have a political crisis on its hands - lack of physician access and long waiting lines to see physicians.

The time has come to “think the unthinkable,” that millions of Americans will no longer have ready access to physicians. There may be solutions to this problem - use of non-physician extenders, government subsidies of primary-care networks, new medical schools, self-care, and long waiting times to see physicians - but those steps will take time and money.

What is likely to happen with greater physician shortages as the 40 percent cut in physician incomes takes effect? How will the existing physician population react?
• Demand for healthcare will soar as the physician supply bottoms;
• A two-tier system will evolve as physicians see those able to pay market rates and others defer treatment for those on government plans;
• Patients who seek services not covered by Medicare and Medicaid, such as Botox, cosmetic procedures, Lasik eye surgeries, and paying the market price will be seen on the same day or the day they request;
• Physician shortages will intensify, creating a political crisis, as 30 million Medicaid, 78 million baby boomer Medicare eligibles, and millions more dropped by employers, enter the market;
• Concierge practices, where patients pay $1,500 to $2,000 a year, for the privilege for being seen promptly by physicians and for using the physician rather than third parties as their agent, protector, and navigator, will explode;
• Society’s most vulnerable populations will have less access to care than before Obamacare became law;
• More and more patients, unable to find a primary-care doctor will crowd into overcrowded emergency rooms, where they will wait for hours to be seen; and
• Twenty percent will leave without being seen because they cannot tolerate the wait.

Government will have a patient and physician revolt on his hands.

MD, is pathologist, editor, author, speaker, innovator, and believer in abilities of practicing doctors and their patients to control and improve their health destinies through innovation. The author of 11 books, his latest is "The Health Reform Maze: A Blueprint for Physician Practices He can be reached 

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The focus of the 2012 presidential election now centers around the future of Medicaid and Medicare.

Author | Richard L. Reece, MD

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