Massachusetts has more doctors than your state

Massachusetts, it seems, is in the midst of a severe primary care shortage:

Half of primary care practices in Massachusetts are closed to new patients and wait times for appointments continue to be long, according to a new survey released today by a statewide physicians' association.

The Massachusetts Medical Society, which has been polling doctors, hospital executives, and medical educators for nine years, reports that primary care doctors are in short supply for the fifth year in a row, citing pressure from the state’s 2006 law mandating near-universal insurance coverage. Other doctors are not immune. All told, 10 of 18 specialties also have shortages and all of the state’s community hospitals say they are having a hard time filing vacancies.

But a visit to the Kaiser Family Foundation's tremendously awesome statehealthfacts.og resource reveals that, at least in raw numbers, Massachusetts doesn't seem to be in bad shape. Relatively speaking. If we look at "Nonfederal Primary Care Physicians per 1,000 Population" we see that in 2008 Massachusetts had the highest number of primary care physicians (PCPs) per 1,000 people of any state (it tied with Vermont).* Massachusetts and Vermont both had 1.8 PCPs per 1,000 people.

"But," you say indignantly, "Massachusetts has near-universal coverage! You can't just compare it to every other state like that!" And that's true. Assuming people without insurance are very unlikely to see a PCP, it seems Massachusetts probably has more primary care patients per 1,000 people than other states, too. But suppose we were to take the uninsured segment of each state's population and cut them out of the equation. That is, let's just look at the number of PCPs per 1,000 insured people. That should knock Massachusetts down a few pegs, right?

And it does. Almost. When we adjust for all the states' insurance rates, we find that Massachusetts is no longer tied for first place. It's now tied for second (with 1.9 PCPs per 1,000 insured people). Still not too shabby. How do we explain this apparent discrepancy between the numbers and the reality? How can Massachusetts have more doctors per capita than (almost) anybody but still be facing such a severe shortage?

I'm drawn to the explanation suggested in "Physician Workforce Crisis? Wrong Diagnosis, Wrong Prescription." The authors argue that not only is the shortage not a problem of numbers, more doctors would actually worsen our problems:

We believe that the perception of a physician shortage, both nationally and in Massachusetts, is just one symptom of the underlying problems in our health care system. The current delivery and payment systems often make it more “efficient” for primary care physicians to see patients they already know (diminishing others’ access to primary care) and for all physicians to narrow their scope of practice (increasing referrals to specialists) and to admit patients to the hospital (where hospitalists manage their care). Data showing that physicians in high-supply regions are more likely to report difficulty gaining both hospital admissions and specialist referrals are consistent with this hypothesis. In the absence of reform of the delivery system, additional growth will lead to further fragmentation of care that will exacerbate the problem of access and worsen the apparent scarcity it is intended to remedy.

Rather than treat the symptoms, we should focus on the underlying disease — a largely disorganized and fragmented delivery system characterized by lack of coordination, incomplete patient information, poor communication, uneven quality, and rising costs. Pilot projects intended to address these problems are under way in both the private and public sectors, with growing interest in primary care–based medical homes, enhanced care coordination, programs for chronic-disease management, and payment reform.

Food for thought.


*Not counting the District of Columbia as a state--D.C. is far and away the winner in this category.

Eat lead, slackers!

The latest latest CNN/Time poll has Ted Strickland up 1 point. This after having been down 10-11 in other polls in the not-too-distant past. I should note that this is the only poll that's shown him up recently.

But it's possible that after sustaining a very long, extended barrage from his opponents, Governor Ted is fighting back. Here's a dramatization:



Go get 'em, Ted!

Some Numbers

Well, the demagogue from Michigan held me personally responsible for causing 10.1 percent of our work force to be unemployed. But 7.4 percent of them were unemployed when we got here. By my figures, we're only responsible for 2.7 percent.

-- Ronald Reagan, October 14, 1982

It's October. A first-term president warily stares down the approaching midterm elections, cognizant of the fact that his party is heading for losses. The unemployment rate is persistently high and the economy is in poor shape. The year, of course, is 1982.

Some folks feel the need to suggest that Obama's economic performance, particularly when it comes to the unemployment rate, doesn't compare favorably to Reagan's. Yet at this point in his presidency, Reagan was facing a 10.4% unemployment rate. And it was rising, on its way to hitting 10.8% in November and December of 1982. The month he took office it had been 7.5%.

By comparison, when Obama took office the unemployment rate was already higher, 7.7%. But last month and the month before that it hovered at 9.6%. If we use Reagan's logic from the opening quote, that means Obama "owns" a 1.9% increase in the unemployment rate. Not too bad, considering.

But this misses the real story. Just looking at the instantaneous unemployment rate when Reagan or Obama walked into office--7.5 and 7.7 percent respectively--doesn't give us an idea of the magnitude of the problem. What we really need to consider here is the derivative: how fast was unemployment changing?

And while this fact seems to have been rather quickly forgotten, the economy really was in free fall 21 months ago; we were hemorrhaging jobs at an alarming rate. Take it from this February 2009 CNN article:

The latest job loss is the worst since December 1974, and brings job losses to 1.8 million in just the last three months, or half of the 3.6 million jobs that have been lost since the beginning of 2008.

The loss since November is the biggest 3-month drop since immediately after the end of World War II, when the defense industry was shutting down for conversion to civilian production.

Got that? We hadn't lost so many jobs that quickly for a sustained period of time since we demobilized the war machine after V-E and V-J day. Let that sink in for a second.

You can see the monthly unemployment rates going all the way back to Truman here. Since it often helps to make a point visually, I stuck some numbers into an Excel chart: the unemployment rates under Obama and Reagan in their first two years in office. However, to give that perspective on how that rate was changing when they showed up, I've also included the numbers for the 12 months before they came into office (i.e. 1980 for Reagan and 2008 for Obama). Go ahead, click it.



You can see that for Reagan the unemployment rate was mostly hovering around that mid-7% range when he took office, whereas for Obama the unemployment rate was riding a rocket to the moon. But not too long after Obama's Hundred Days ended the unemployment rate began to level out and eventually came down a bit. Today it hovers in the mid-9% range. This understates the pain, as that number doesn't tell us how many people have gotten discouraged and given up looking for work or who are stuck working part-time when they really want to be working full-time. But it certainly beats an unemployment rate of 14% or 18%.

I don't mean to suggest the current situation is acceptable; it isn't. Obviously that unemployment rate needs to come down. But it helps to stop once in a while and remember that things were downright terrifying at the start of 2009 and at the time the possibility of Great Depression II didn't seem all that remote. And despite the vast differences between the economic situation today and that of the early 1980s, remember that the unemployment rate right now is a full 0.8 points lower than it was in October 1982 and, as far as I can tell, it's not on its way up. So based only on the first two years of their first terms, I'd have to say Obama outperformed Reagan, getting a (comparatively) better outcome despite facing a decidedly worse situation.

Federalism and the Other Elastic Clause

Like many people, sometimes I'm conflicted on federalism. That is, I find it difficult to sort out an entirely consistent picture of the role I see for the states and the federal government. I was dismayed when Missouri voters passed Proposition C earlier this year, effectively instituting a state law that insulated them from the federal mandate to carry health insurance. "The Supremacy Clause is clear," I said indignantly, "this is purely symbolic because states don't have the authority to overturn federal laws." I reject the notion that states can nullify federal law.

And yet I'm secretly rooting for California's Proposition 19 this year, the state's ballot initiative to legalize marijuana. And what's the difference? Is it simply that I don't like federal drug laws--particularly with regard to marijuana--but favor health care reform? Perhaps. Everyone's a hypocrite sometimes. This hypocrisy occurred to me today when I found myself disappointed that the Attorney General announced his intent to crack down on pot if Prop 19 passes:

SAN FRANCISCO — The U.S. government will "vigorously enforce" federal laws against marijuana even if voters next month make California the first state to legalize pot, Attorney General Eric Holder says.

Holder's warning, contained in a letter to ex-federal drug enforcement chiefs, was his most direct statement yet against Proposition 19, and it sets up another showdown with California over marijuana if the measure passes.

Let me return briefly to the example I brought up in "Happy (Belated) Constitution Day": Thomas Jefferson and his Democratic-Republicans approving the Louisiana Purchase, an action not explicitly authorized in the Constitution. An allegedly strict constructionist made a funny argument to me in favor of Jefferson's decision. Jefferson's decision was plainly constitutional, I was told, because the Louisiana Purchase was the result of a treaty with France. And since the Constitution does grant the federal government the treaty power, there is no issue here. In practice, land acquisitions are often part of treaties, after all. Of course, this is true; Article II, Section 2 does tell us the President has that power:

He shall have Power, by and with the Advice and Consent of the Senate, to make Treaties, provided two thirds of the Senators present concur;

But it seems to me that there's something odd about this. Accepting it requires acknowledging that enumerated powers of the government come with various, potentially wide-ranging, implied powers that are not explicitly written down. And this is a very Hamiltonian sort of view--he used it to win the argument that a National Bank (not explicitly authorized in the Constitution) was constitutionally acceptable, a position Jefferson and Madison didn't share. One might think that conceding that the Constitution allows for actions not enumerated in it completely undermines the strict constructionist position. After all, the philosophy that the Constitution allows for actions not explicitly inked on the page is what loose construction is all about.

But let's step back to Proposition 19. Drug policy isn't my forte so I found myself wondering wherefrom Congress derived its authority to regulate and outlaw drugs. Now, usually I'm fairly sympathetic to federal power. But it's well-known that the Prohibition on alcohol required the Eighteenth Amendment to the Constitution so I was curious as to how Congress was able to prohibit other drugs without something similar. Naturally, I started with a trip to the Wikipedia article on the Controlled Substances Act to get my bearings on the subject. And I was surprised to find the justification for that law:

The Congressional findings in 21 U.S.C. §§ 801(7), 801a(2), and 801a(3) state that a major purpose of the CSA is to "enable the United States to meet all of its obligations" under international treaties - specifically, the 1961 Single Convention on Narcotic Drugs and the 1971 Convention on Psychotropic Substances. The CSA bears many resemblances to these Conventions. Both the CSA and the treaties set out a system for classifying controlled substances in several Schedules in accordance with the binding scientific and medical findings of a public health authority.

The feds can regulate drugs because we agreed to in a treaty? Now that's fascinating. Very reminiscent of the argument that Jefferson could double the size of the United States because a treaty was the vehicle for doing so.

But wait a minute. Does this imply that the federal government can do absolutely anything as long as its actions are in pursuance of treaty obligations? For example, the U.S. is a signatory to the Universal Declaration of Human Rights. This isn't a treaty. But suppose some administration took that language and stuck it into a "treaty" with, say, Canada. Both nations pledge to each other that they'll abide by those principles. Of course, treaties require approval by 2/3 of the Senate so adopting that faux treaty would be only slightly easier than simply passing a constitutional amendment. But this is a thought experiment so let's suppose that this U.S.-Canada treaty is ratified by the Senate and compliance with the Universal Declaration of Human Rights becomes a cornerstone of our relationship with Canada. That means, for example, our treaty obligations would require us to match policy action to words like these:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

Presumably the federal government would then have carte blanche to regulate and/or provide health care in any way it chose, no (constitutional) questions asked. All because the treaty power is written into the Constitution. If strict constructionists buy that, then isn't the treaty power essentially an infinitely elastic clause (much more so than the actual Elastic Clause)?

For the most part, treaties don't seem to be used this way (perhaps in no small part due to the Senate supermajority approval stipulation) but that sure opens some doors, doesn't it? Anyway, anyone want to help me reconcile my revulsion to state nullification of the health reform law with my secret affection for California's attempt to locally overturn federal prohibitions on pot?

Life, Philosophy, and Policy

A while back (in Unpersons) I mentioned an approach to the abortion question that, while maybe not a consensus among folks on the left, at least seems to be fairly common, if not always articulated: namely, that the question of whether or not abortion is acceptable hinges on questions of social personhood and not biological life.

In some ways this is a deeply philosophical point and when it comes to public life perfect intellectual consistency usually isn't the order of the day. Consider the Children's Health Insurance Program (CHIP), government-financed health insurance primarily for kids who don't quality for Medicaid. Both Medicaid and CHIP have special (higher) eligibility thresholds for pregnant woman. Since 2002 states have also been allowed to exercise a so-called "unborn child option" that allows them to consider a fetus as a "targeted low-income child" for CHIP coverage. Currently, 15 states do this: Arkansas, California, Illinois, Louisiana, Massachusetts, Michigan, Minnesota, Nebraska, Oklahoma, Oregon, Rhode Island, Tennessee, Texas, Washington, and Wisconsin.

Of course, it's not really possible to disentangle providing care to a pregnant woman from providing it to an unborn child so what exactly you call it is sort of academic. Is it a special benefit for a pregnant woman (a vulnerable member of society) or is it a benefit for an unborn child, implicitly acknowledging that fetus as a member of society? Whatever. But it does have philosophical ramifications because, at least ostensibly, that defines how you're thinking about it. And it would seem that designating a fetus--what I previously called an unperson--as a child, a person eligible for social benefits is a firm pronouncement that the unborn are not just biological lives but persons. And persons, presumably, are subject to societal protection, not just from ill health (thanks, CHIP!) but from termination.

So why have these states decided to exercise the unborn child option? Is it a bold philosophical statement about the ontological status of the unborn? In general, no, probably not. You see, unborn children don't have a citizenship status. Thus if you choose to provide care to them, you can do so without worrying about the citizenship or residency requirements that characterize public assistance programs. And, like I said, in a practical sense you can't really disentangle providing care to a pregnant woman from providing it to an unborn child. So states can use the unborn child option to provide CHIP health care benefits (in this case, prenatal care) to otherwise ineligible pregnant illegal immigrants* by (*wink*) targeting it at their unborn child.

So an ostensibly key piece of the philosophical puzzle here turns out to be a policy tool to get around some practical political constraints. Pragmatism might arguably have desirable outcomes but it doesn't do much for producing a cohesive philosophical view of the universe.

*These woman would be eligible for emergency coverage of labor and delivery but not the full package of prenatal care before that.