Tracing the decline of health care in America

There is an old truism with respect to medical care: We want it excellent, we want it fast, and we want it cheap; but we can only ever have two of the three.

During the first 90-plus years of the 20th century, the United States had the best quality and availability of health care on the planet; but it was not the least expensive. There was a good supply of talented physicians and surgeons, with a pipeline of talented students and training programs to re-supply it. Bright young people saw medicine as rewarding, both emotionally and financially; so many of our "best and brightest'" chose that career path. Payments to physicians by commercial insurers and Medicare were mainly market based, like all other professions and trades.

In 1973, U.S. Sen. Edward Kennedy initiated, and Richard Nixon signed, the HMO Act, which allowed "Health Maintenance Organizations" (an inaccurate, marketing moniker for insurance plans) to be formed and encouraged many companies and patients to join them. That did not have much influence on our system until about 1995 (see below). Also in 1973, Nixon put a temporary "freeze" on all physicians' fees.

In 1992, Medicare arbitrarily decided certain surgeries and pathology services were "intrinsically over-valued"; the fees paid by Medicare were slashed dramatically. Other procedures followed. Insurance companies then did the same (but no one lowered their premiums).

The next attempt to alter our health care system was the Clinton Health Care Plan of 1993 (aka, HillaryCare), which was a reform package proposed by the Bill Clinton administration. The goal was to come up with a comprehensive plan to provide universal health care for all Americans, which was to include an enforced mandate for employers to provide health insurance coverage to all of their employees. Opposition to the plan was heavy from pharmaceutical firms, health insurers, employers, and politicians; many legislators offered a number of competing plans. On Sept. 26, 1994, the bill was declared dead by Congress. But other players stepped in, especially HMOs.

In 1997, in a misguided attempt to reduce health care costs by limiting availability and thereby reducing utilization, Congress reduced the funding of (thus the number of) residency training programs. During the intervening decades, the number of federally funded residency slots has remained effectively frozen, progressively worsening the country's physician shortage through attrition, as well as by population growth and aging of our population. Thus it has temporarily succeeded in reducing costs by reducing availability: people are waiting ever-longer for care, including urgent and emergency care. To reduce the backlogs, we have been using lesser-trained providers, such as Advanced Practice Registered Nurses (aka nurse practitioners or APRNs) and physician assistants (PAs). So what Congress did was sacrifice both quality and availability for reduced costs. (There is a bit of potentially good news on the horizon: Congress is now considering the Resident Physician Shortage Reduction Act, a bipartisan bill that would add 14,000 new Medicare-supported residency slots over the next several years -- marking the most significant expansion of the physician training pipeline in nearly 30 years.)

Since the mid-90s, both insurers and Medicare have dictated fees for medical services, on a "take it or leave it" basis. Insurers, especially HMOs, also began to deny services (often arbitrarily and motivated by profit) that they should have covered, for reasons such as "pre-existing" or "not medically necessary." Additionally, the litigiousness of our society forces physicians to practice expensive "defensive medicine," ordering tests that are medically unnecessary -- to protect against malpractice claims. In a discussion of this, a friend quoted me a sentence from Stephen King's "The Green Mile": "I'm growing very tired of being shown the light, by people who can't do what I do, but know I'm not doing it right."

The Affordable Care Act (aka, ObamaCare or the ACA) became law in March of 2010, with mostly good intentions. However, it has caused a huge increase in Medicaid enrollment, with a consequent huge increase of demand by patients for these cost-free (to them) services; this was and is a significant factor in the relative shortage of care today, as well as increased total cost to taxpayers. Also, since Medicaid has always paid hospitals and providers so poorly (by design, it pays less than the actual cost of providing care), commercially insured patients wind up paying more than they otherwise would (this is in addition to supporting Medicaid with income taxes).

Adding to this is the increasing (and reasonable) desire of millennials for a better "work/life balance," thus demanding shorter hours, less time on call, and therefore fewer patient encounters per physician than previously. While some of the lost availability is replaced by APRNs and PAs, they do not have the same levels of expertise.

Even altruism has its limits. The "best and brightest" are realizing that a career in medicine may not be worth pursuing, as it involves 12 to 16 years of rigorous education and training after high school before being able to enter practice, followed by a life-long battle with insurers to get needed care approved. Add to that the detail that medicine is the only profession or trade in the United States whose fees and rules are dictated by others, i.e., insurance companies and the federal government (Try telling your electrician or accountant what their fee will be, or how to do their job). Then there is the constant threat of claims of "malpractice."

It is no wonder that so many very bright people now prefer other careers, and that we have an increasing shortage of qualified physician-providers.

Anthony Musto, a 1968 graduate of Georgetown University School of Medicine, is a retired ophthalmologist who practiced in Connecticut (Bridgeport, Stratford and New Haven) for 51 years, 1973 to 2024; and who has experienced the decline of our health care system as both a physician/surgeon and a patient.