health care

How To Make Health Care More Affordable

Virginia's new Democratic politicians have a chance, but it goes against their partisan instincts.

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Virginia's new Democratic governor, and its new class of Democratic lawmakers, have an opportunity to improve access to health care in Virginia. But to do so, they might have to go against their partisan instincts.

Gov. Ralph Northam already has made Medicaid expansion one of his top priorities. Republicans don't like the idea. But their recent abandonment of divisive social causes such as abortion and anti-LGBT issues suggests they might be more receptive to compromise on Medicaid as well.

Then again, maybe not. Regardless, Democrats and Republicans should be able to find common ground on two other approaches to expanding health care.

The first is a bill from Republican Del. Roxann Robinson. HB 793 would let nurse practitioners practice medicine independently, rather than under the thumb of a supervising physician, after a probationary period of supervision.

At present, nurse practitioners in Virginia must have a contract to work under a doctor's watchful eye. If a nurse can't find a doctor to agree to such an agreement, the nurse is out of luck. If a doctor retires or dies, the nurse is out of luck. If a doctor joins a group practice with restrictive rules, the nurse is out of luck again.

Roughly half the states in the U.S. already permit advanced-practice nurses to operate independently. A huge body of research has validated the approach. The Institute of Medicine recommends it because the rules limiting nurse practitioners "are related not to their ability, education or training, or safety concerns, but to the political decisions of the state in which they work," and because "most studies showed that NP-provided care is comparable to physician-provided care on several process and outcome measures. Moreover, the studies suggest that NPs may provide improved access to care."

The Department of Veterans Affairs adopted the reform last year. The Kaiser Family Foundation endorses it. The Federal Trade Commission also supports expanding the ability of nurse practitioners to perform medicine independently, which would provide "safe, lower-cost competition" to physicians. Likewise, it would increase the supply of medicine in underserved areas, such as rural areas, where there is a serious shortage of doctors, as well as statewide. (By one estimate, Virginia will need 29 percent more doctors by 2030 to maintain the status quo.)

Other research has shown that giving nurses a greater scope of practice helps bring costs down by as much as 35 percent, with higher levels of patient satisfaction.

That's the first reform. The second? Repeal the state's Certificate of Public Need (COPN) requirements.

Virginia's COPN regime requires health care providers to get the state's permission to spend their own money on investments such as new hospital wings or major medical devices such as MRIs and CT scanners. The process is hugely expensive and time-consuming — in large part because market incumbents, such as large hospital chains, are allowed to weigh in on whether the state should permit new entrants to compete with them.

Congress originally imposed the system to deal with a problem caused by federal reimbursement rates for Medicare and Medicaid. Washington eventually changed the reimbursement formulas and lifted the COPN requirement, but many states (including Virginia) kept it in place.

In theory, COPN is supposed to control health care spending through central planning. In practice, it doesn't. Washington state found, for instance, that "CON has not controlled overall health care spending or hospital costs." A commissioner for the Federal Trade Commission has written: "Ironically, a government program originally aimed at reducing health care prices is likely inflating them, at least in some situations."

The FTC and the Antitrust Division of the Justice Department have repeatedly argued that certificate-of-need laws "undercut consumer choice, stifle innovation, and weaken markets' ability to contain health care costs. Together, we support the repeal of such laws, as well as steps that reduce their scope." As they told a Virginia working group in 2015, "the evidence to date does not suggest that CON laws have generally succeeded in controlling costs or improving quality."

In fact, large health care providers now argue exactly the opposite: By stifling competition, COPN laws help hospitals generate excess profits that they can then use to pay for indigent care. Virginia sometimes even requires charity care as part of the price for granting COPN approvals. In other words, a program originally imposed to lower costs is now justified on the grounds that it raises them.

Giving nurses greater freedom to practice and repealing COPN would both lower costs and expand access to care. To achieve either, however, lawmakers will have to overcome opposition from powerful physician and hospital lobbies. Gov. Ralph Northam's views on the issues are opaque, but as a pediatric neurologist he might have concerns that need to be overcome as well. And Democrats, who are philosophically inclined toward more regulation rather than less, might have to overcome their own instincts in that regard. But if they can, patients across Virginia would benefit.

This column originally appeared in the Richmond Times-Dispatch.

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  1. Two words: price controls.

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  2. Make it free. Free is affordable. How is free not affordable?

    1. After all, Democrats care about people.

      1. Tony sayeth, so sayeth we all.

    2. I’m hoping that was sarcasm… but in case it wasn’t…

      There is no such thing as “free.” Someone has to pay for it. Whoever pays for it controls it. If you want to control your own life and health, you have to pay for it yourself. The high cost now is a result of the efforts to make health care “free” for some people, by increasing the cost to others. If you don’t care who is robbed to pay for it… too bad.

      1. There’s never any sarcasm on here.

  3. Prediction: none of the good things will happen.

  4. You’re incorrectly assuming that Democrats want to help Americans rather than just fleece them.

  5. Federal Trade Commission has written: “Ironically, a government program originally aimed at reducing health care prices is likely inflating them, at least in some situations.”

    Supply and demand, how does it work?

    1. Seriously, this would have been predicted by anyone with even a modest understanding of economics.

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    1. Your income fluctuates by 50% per month? Are you being paid in bitcoin?

  7. In theory, COPN is supposed to control health care spending through central planning. In practice, it doesn’t.

    Shocking.

    What saddens me most is that libertarians can’t successfully run against laws like these on moral grounds.

  8. Virginia’s new Democratic politicians have a chance, but it goes against their partisan instincts.

    Northam’s speech to the legislature was pretty partisan. Apparently his primary goals are medicaid (welfare) expansion and further violation of A1S13 of the State Constitution. And there’s probably enough squishy Team Red pols to give it to him.

  9. “anti-LGBT”

    also known as not wanting creepy men in the bathroom with my wife and daughter

    1. Snarky answer: Then stop following them in.
      Still snarky answer: Then stop demanding that transmen follow them in.

      Seriously folks, I get that everyone obsesses about transwomen, but transmen are a thing too. And if you demand that transwomen use the men’s room, you’re also demanding that transmen use the women’s room. So you aren’t avoiding transfolk in the women’s room, you’re just choosing whether you want them with a beard or a dress.

      1. The difference? A woman that says she’s a man doesn’t usually opt for surgery and don’t kill themselves anywhere near the same rate.

  10. If the goal is simply reducing the cost of healthcare, there is a far more simple way to achieve. Ban the sale of health insurance, ban the ability of enterprises in paying for the healthcare of their members. That includes ending all federal insurance programs and subsidies.

    If you make every american pay in cash their healthcare costs, you will see a reduction in total healthcare spending on the order of 80%. Instead of $2.4 trillion, total spending would drop to the somewhere around the order of 450 billion USD on an annual basis. Be prepared for a few million unemployed healthcare workers, and about 75% of all healthcare facilities to go bankrupt. But, it will reduce the cost of healthcare the most, the fastest.

    1. Iffy.

      A very casual cost comparison with folks I know in medicine suggests basic services (general lab work, check-ups, some meds, etc.) is cheaper under government contract. You could even utilize PHS if you wanted.

      Beyond that is up in the air, and I suppose you could have some nationwide charities also negotiate their own contracts, so there’s that.

      The best argument I’ve heard is ideally you’d want to engage in cost cutting measures prior to even thinking about nationalized healthcare just to reduce graft and accurately gauge if a national plan would be useful at all.

      As it is though, the collusion of insurance to keep profits high is all but making some type of nationalized medicine all but inevitable as the public feels the pinch and demands government do something about it.

    2. First step: Repeal prescription laws, which were signed into law by FDR in 1938 at the behest of the American Medical Association. This strips doctors of their profitable government enforced monopoly over access to medical drugs. Allows people to take care of their own health to the best of their abilities. Allows people to obtain the assistance of pharmacists as to what medications they should use at far less cost than what MD’s now charge.

  11. Umm…if a NP wants to practice medicine without oversight perhaps they should have become an MD instead?

    I’m not saying you’re wrong, but it’s amusing to watch people argue that this or that medical professional is ‘just like’ a doctor except for the whole bit where they aren’t a doctor.


    Moreover, the studies suggest that NPs may provide improved access to care?”

    Oh really? It suggests that it might perhaps could be maybe improve a nebulous metric like ‘access to care’. Well, maybe, since it theoretically expands supply but do you think their malpractice insurance won’t go up now? Or that nothing else will change in response?


    The Federal Trade Commission also supports expanding the ability of nurse practitioners to perform medicine independently, which would provide “safe, lower-cost competition” to physicians.

    Haha, yeah. So because we fucked the physicians into the ground with onerous regulations we need to let some other type of medical professional do what they were doing for cheaper before they were fucked by said regulations.

    Yeah, sorry, I don’t think this is as ‘smart’ as it’s made out to be. Maybe just unfuck the Doctor’s but I guess that’s just too logical. Why do you think so many are going for the lower education, cheaper, less regulated profession in the first place?

    1. Here in California, a lot of drug stores have clinics with a nurse who does basics and refers you if your problem is above their pay grade. If you’ve got a runny nose or flu, you can get a checkup and prescription in an hour instead of waiting a week till the doctor has an opening. If it’s just a runny nose, they give you a prescription. If it looks like more, they send you to a doctor or for emergency care, but you haven’t waited a week to start treatment if it’s something serious.

      I agree that making things less onerous for doctors is also necessary. But even at that, unless we’re going to create a lot more doctors with a lot lower salary expectations – which the AMA will fight tooth and nail – it makes sense to have access to basic care through a related but different channel.

      1. In a libertarian society all professional organizations would be illegal. They all operate on a basic of “restraint of trade” using the “guns of government” to increase their own incomes. No different than a labor union which restricts the supply of available employees so that employers have to pay more. (the minimum wage serves the same purpose). Licensing of occupations by the government is another method to increase incomes at the expense of everyone else.

    2. Then there are those of us fucked over by the competition, that controls our licenses through the good ole boy system. Did you ever how the classification of disruptive physician occurs? Try standing up for the little guys from whom the administration wants to drain every bit of blood. Never try to save your patients a buck! But, then the big shots won’t get their graft!

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  13. Doing things like repealing prescription laws (passed in 1938 by FDR) would also considerably reduce the cost of health care. Mainly because without prescription laws, doctors no longer enjoy the profits from having a legal monopoly over access to medical drugs.

    Without prescription laws, you would be able to take care of things like high blood pressure and high cholesterol, two of the major causes of heart attacks and strokes for a yearly cost of about $80 a year (Walmart generic prices). Whereas as it stands today, you’ll spend several hundred dollars for office visits and lab tests just to get “permission” to buy the $80 worth of generics at Walmart.

    1. As a retired physician, I can wholeheartedly agree! I could get my family the prescriptions they needed with no additional expense to any of us. And we could save the $250/yr that each of us are paying out for those biannual visits! But, that is only if you can get your doctor to agree to see you just twice a year at the age of 65! Handling the opiates would be a little more difficult. But, if the truth was told, medical patients are not dying from treatment of their pain. The people that abuse heroin laced with Fentanyl are the ones that make up the 15,000 or so a year dying from “accidental opiod overdose”. That also does not report on overdose deaths related to suicide. There might be a spike in suicides by pain patients, like me, who will refuse to live in pain that could be compassionately cared for by “real doctors”! Don’t people realize how minuscule that number is, when compared to hospital deaths due to mistakes, or deaths from cigarettes and alcohol?! And who watches the dentists. My wife has insurance. Her dentist always manages to fill two teeth every visit, one of which the insurance will not pay for! They soak us and the insurance company! Is it any wonder that dentists were listed as the best paying jobs mention on the financial news that I recently heard?!

  14. There are a million other medical reforms that need to happen too, but both of these are sensible.

    The fact is that there are different grades of skill needed to deal with different problems. Nurses can do basic basic stuff, RNs can do more complicated stuff, doctors more complicated still, and specialist surgeons etc the craziest of stuff. The fact that in many places you’re legally required to pay for a greatly over qualified Dr. to deal with something a regular nurse or RN can do is retarded.

    An RN can look in your ear and go “Yup, you have a typical ear infection. Here’s your prescription.” And DONE. Same for 100s of other minor things. You don’t use a semi truck to pull a single jet ski, because it’s dumb. So why the overkill on medical stuff? Division of labor is what makes the modern world possible, but it is legislated out of existence in medical to a great degree.

    If we were really smart we could even train nurses to have specialties where they have doctor like levels of knowledge in a narrow field, but not broad based skills like a doctor, and only deal with certain things reducing costs further. Think Ear, Nose, And Throat RN who needed less than half the schooling of a Dr. and can cost dramatically less. Every other market has done this to great effect.

    1. Basic principle of the “guild”. Use of “force” to prevent competition from others. Professional organizations, labor unions, licensed occupations. All depend on “the guns of government” to create income levels for themselves well above what the free market would charge for these same services. Organizing to “improve” your own welfare at the expense of everyone else likely goes back to the early civilizations in the Middle East. Or early historical China in the time of Confucius. Or pre-historical “witch doctors” who carefully guarded their own knowledge of herbs and potions back in the Stone Age.

  15. 1. Listed prices, price transparency
    2. End blanket consent (another doctor cannot come in, look at you, and charge you thousands, without YOUR consent)
    3. Allow the importation of drugs

    Tweaking insurance will never reduce costs.

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