Jonathan Cohn

Defending Romneycare (Because Romney Won't Do It)

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A new report on health care access in Massachusetts has given conservatives a new opportunity to say “told you so” about Romneycare and the Affordable Care Act.

The report is the annual physician workforce survey from the Massachusetts Medical Society. It says that large numbers of primary care doctors, including more than half of family physicians, aren’t taking new patients. It also says that average waiting times of 30 to 40 days are common in many specialties.

Opinion writers at Forbes, the National Review, the Wall Street Journal, and the Washington Examiner, among others, say this proves Romney’s Massachusetts health plan has failed and that the Affordable Care Act, which expands insurance coverage in a similar way, will fail as well. “The ObamaCare preview that Massachusetts has been conducting for the last several years grows more ominous by the month,” the Journal says. “Perhaps you should book your checkups now, in advance of the national sequel.”

But the report tells a far more complicated story, one that may not have much (if anything) to do with health care reform. And since Romney himself isn't making this case--I assume he just wishes the whole topic would go away--let me give it a shot.

While the long waits for physician services in Massachusetts seem real enough, the very same survey reveals that the long waits existed before Romney’s law took effect in January, 2007. You can see for yourself in the following graphs, which document the trends for physicians of internal medicine and gastroenterologists:

It's hard to spot a clear trend here, particularly if you discount that 2006 internal medicine figure as an anomaly. It's even harder to spot a clear trend if you go through the report and examine the responses from other types of doctors. Reported wait times go up and down, year to year, which is precisely the sort of statistical noise you'd expect from a survey that relies on small samples size and the non-scientific testimony from physicians. Evidence of longer waiting times since the introduction of Romney's plan seems thin, at best.

Elsewhere, it appears that primary care physicians (although not specialists) are becoming less likely to see new patients. And that's certainly worrisome. But that decay was also underway before the Massachusetts reforms: It doesn't appear to have accelerated starting in 2007. The Journal and others also point to a 2010 study on rising emergency room usage between 2004 and 2008. But, again, the rate of increase didn't change after reform: It was going up before the coverage expansion took place. In fact, the most detailed study of ER usage in Massachusetts I've seen comes from Sarah Miller, a graduate student at the University of Illinois. It suggests that reform's direct effect was to reduce utilization, albeit very slightly.

To be clear, I wish we had evidence that reform reduced ER usage significantly. It obviously hasn't and critics have every right to point that out, although I remain hopeful that reform can ease the ER load over time. I’ve also heard plenty of anecdotes about long waits in Massachusetts, so I'm not dismissing the possibility reform has exacerbated the crowding problem. 

But my strong hunch is that the real story in Massachusetts is an old one that's plagued the entire country for some time now: We don't have nearly enough primary care providers. As Nancy Turnbull, a longtime state official who now lectures at Harvard, told the Boston Globe after last year's ER report, “I don’t think the increase has anything to do with health care reform. It’s much more reflective of [primary care] access problems.’’ 

Solving that will likely require increasing the supply of pediatricians, family doctors, and geriatric physicians, as well as nurse practitioners and others who can handle primary care duties. The Affordable Care Act actually addresses that problem, by boosting primary care reimbursements. It may not be enough, but it would seem to be a step in the right direction--particularly since, whatever its modest effect on physician availability, it will provide financial protection to tens of millions of people. 

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