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Re-thinking Who Becomes A Doctor

Let me echo Jonathan's recommendation about those two health care pieces you should read. In the Times, David Leonhardt hit on a theme I've been thinking about a lot since health care reform became Topic A a few months ago, which is the basic sociology of doctoring:

[Obama's] rhetorical choices highlight one of the least discussed but most important conflicts in the current health care debate. The fight isn’t just a matter of Democrats vs. Republicans, Blue Dogs vs. liberals or patients vs. insurers. It is also doctors vs. doctors. ...

“There are no consequences right now to over-utilization,” Dr. Anthony F. Oliva, chief medical officer of the Guthrie Healthcare System, in northeast Pennsylvania, said later. “If you don’t have consequences, you won’t change the culture. If you don’t have consequences, the people that are killing themselves to control cost are going to say, ‘Why am I doing this?’ ”

Given how much of the game of reining in costs hinges on doctors--whether they see themselves as profit-maximizing small businessmen (or, for that matter, large businessmen), or as fundamentally involved in healing patients and receiving fair compensation for that service--I think we have to think about the kinds of people who go into the profession. (That great Atul Gawande piece hits on this, too.) If most of the profession consists of the former type, it's going to be really, really hard to get the cost situation under control. If it consists mostly of the latter type, then we have a real shot.

Of course, the nice thing about health care reform is that, if you move to more of a Mayo Clinic style-system (salaries rather than a kind of commission based on volume of treatments and procedures), you'll eventually discourage most of the first type from entering the profession--they'll go open car dealerships instead. (Okay, maybe not car dealerships these days...) But if these people currently account for a substantial portion of the profession--and surely they do--you see how getting from here to there could be a real pain.

Meanwhile, in the Post, Ezra Klein made an absolutely terrific point about the prescience of Clintoncare: 

By the time Clinton and his team took office, the insurance market was changing. American consumers had traditionally relied on the most straightforward of insurance products: indemnity insurance. You went to the doctor or hospital of your choice, and that doctor or hospital sent your insurer the bill. Hopefully, your insurer paid it. ... The managed-care revolution of the mid-90s was, by the early years of that decade, clearly inevitable; the financing and delivery of health care could not remain separate forever. But this was a dangerous change. Insurers make money by denying claims. ...

So Clinton sought to cage managed care inside managed competition, which would regulate the behavior of insurers and force them to compete for patients. This would give consumers more power against their insurance companies, drive the bad actors from the market and generally protect against the excesses of managed care. Clinton's plan also included a handful of other safeguards, like out-of-pocket caps and an independent appeals process, designed to protect consumers from deficient insurance. ...

But if Clinton's team of enlightened wonks could glimpse managed care over the horizon, the public wasn't as farsighted. Bill and Hillary weren't seen as meeting and taming the managed-care revolution. The act of writing legislation that included managed care made it seem as if they were proposing it. ... The plan died a painful and public death in Congress and contributed to the GOP's huge gains in the 1994 elections.

But then a funny thing happened: Managed care came anyway. By last year, only 7 percent of American workers were in "traditional" indemnity health plans, while the rest of us -- or at least those of us fortunate enough to have insurance -- were swimming in the alphabet soup of HMOs and PPOs and HDHPs. ... "We got managed care," says Chris Jennings, who was one of Clinton's top health-care staffers. "But we didn't get the things that would protect us from managed care. We got the Wild West version of it."

All of which touches on another theme I've been thinking about a lot lately: How bad do things have to get before public opinion will let politicians do (or insist that they do) what voters would almost certainly support if the pols were able to do it. I've been thinking about this in the context of financial market regulation, but it's probably even more important in the context of health care reform. Clearly not as bad as, say, the Great Depression, I think. But worse than the current recession/financial crisis/health care situation? Maybe...

--Noam Scheiber