The virtuous, politically charged platitudes put forth in the commentary by New York Gov. Eliot Spitzer have a lot of appeal on the surface, but could very easily evolve into another ill-conceived, unfunded federal mandate (Lets complete the job, April 23, p. 24). In its current description, it would undermine the private insurance market and create a single-payer system that will have fewer options than Medicare.
The current structures of Medicaid and the State Childrens Health Insurance Program have not fulfilled the needs of those for whom they were intended nor met the expectations of those who provide care. SCHIP has been used to cover adults and in many states has expended only a minor fraction of funds on children. The system is not user-friendly, with regulatory elements and reimbursement levels that, in many states, have limited the participation of practicing pediatricians. In states where there are an adequate number of doctors participating to provide adequate access to care, many practices will set limits on the number of SCHIP and Medicaid patients, making up for losses through the higher reimbursements paid by private insurance companies.
The promise of adequate payment from Medicaid programs has not translated into sustainable revenue and, more often, has been woefully inadequate. There is no reason to believe that there is a solution in this proposal that could pay for care in a way that could keep the practice of pediatrics viable. By offering every parent a choice (although there doesnt look like they have one in this plan) that decreases their healthcare or insurance costs, there will be a single payer and single payment scheme.
Meanwhile, the entitlement of Medicare is a paradox of disastrous proportions. It relies on low-income workers providing a significant portion of their paycheck to cover the medical costs of seniors who could afford to pay for their own care. Whats worse, there are more seniors coming with greater expectations and more-expensive care options and this will ultimately bankrupt the program. The cost of operating and the low income associated with a primary-care geriatric practice has already created dire professional manpower shortages that will only get worse.
There is a serious problem with the Medicare physician-payment formula that our legislators have not attempted to fix. It is hard to imagine simple solutions that respond to a market need in a bureaucratic system. If you want to have medical care for children, you cant mandate it without understanding what impact it will have on the foot soldiers who perform the services that this plan would require. These are small businesses that employ hundreds of thousands of people in a professional endeavor that is barely profitable and requires exceptional dedication, intellect and effort.
Spitzers program would break the back of pediatricians. It is not a panacea.
Russell LibbyPhysician Virginia Pediatric Group Fairfax