I admit I started reading this article with a bit of skepticism. As an adviser to a Presidential front-runner, Goolsbee would necessarily have to be cautious and nay-saying about making major changes (it's sad that while clamoring for change our voting public is suspicious of anyone who proposes to actually implement it). But I do think that he raises some worthwhile points, and offers a more complex analysis than I would have expected. Still there are many points that strike me as superficial or worse...many of which have been discussed by previous posts. One other point where I think he fails to address the nuances of the issue is on doctors' pay.

As a bit of background, I grew up in a two physician household with my father in private practice (and in an increasingly lucrative subspecialty) and my mother as a hospital physician. It's true that my dad earns a few times what my mother does. But I have to believe that for the trade off of not paying outrageous malpractice insurance premiums and substantial health benefits for his office staff, my dad would gladly accept a pay cut. He'd probably net the same income, but also have the reduced stress of dealing with these issues.

But while I don't think that pay cuts for doctors is a non-starter in the move toward universal health care, there is one issue I've wondered about and would certainly be interested in others' thoughts. I think it is true that the quality of care available to the very rich is excellent in this country...and I have to believe that some of the innovations that people are willing to try because they know they can get some high paying patients eventually become more cost effective and more widely available. Preserving this while increasing the number of insured would seem to naturally lead to a two-tier system of single-payer Medicare type coverage with private coverage for the very rich (or those willing to pay for whatever reason). But I worry then, that all of the best providers would move toward those with private coverage. It's already the case that many physicians won't join managed care programs and the like b/c the payouts are so much lower than less restrictive PPO plans. This might contradict the claim I made earlier about doctors being willing to accept lower pay...but I don't think it is. It's one thing to tell a doctor that we're moving to a single-payer system where you won't have these additional financial burdens in exchange for slightly lower fees/income. It's another to say that the government will pay you $1000 for a procedure, but this private insurance company will pay you $5000 or even more. I think that would create too great of an incentive not to move toward privately covered patients...and the pool of doctors available to the government subsidized program will be smaller and likely less qualified. I'm a strong believer that it does matter which doctor you have and that there are substantial differences in the quality of care different doctors, (and nurses and physical therapists etc) can provide.

I don't know a way around it, but I do think that it's a real issue. I appreciate the desire that many have to preserve something of a market-based system of health care b/c of the increased choice it affords and also the innovation it might be able to drive. But I find some of these things at odds with also trying to provide quality care for those who can't currently afford it.

I wonder what the doctors in, say, the VA systems are like. Do they get paid comparably to other doctors? Do they leave the system on a regular basis, drawn away by the promise of higher money? And what about the doctors in countries with a single payer system? When that country shifted to the single payer system, was there an exodus of doctors? Do many doctors in Canada want to move the States with the promise of more money?

The VA is staffed at least partially my moolighting doctors and possibly residents.

VA doctors take a paycut often on the order of 30% (more for the more lucrative specialties) but as most VAs are associated with medical schools the physicians can get extra income from pharmaceutical companies and grants. Additionally, the draw towards academics and university affilitations keeps the physician quality (mostly) high.

VA specialists make 1/2 to 1/3 of their private practice peers. They also work bankers hours and have zero incentive for productivity.

You're going to get what you pay for in terms of physican quality. If you expect to get by on the cheap, you're going to get (often) less quality-driven services.