WASHINGTON – With the writers’ strike at an end, couch potatoes can sigh with relief. But imagine if labor strife had befallen a far more critical group of individuals — like doctors.
The notion of white coats on the picket lines is not as far-fetched as it may seem. Some doctors believe that unionizing is the only way to wrest control of medical decisions from third-party payers like insurance companies and the government.
Unlikely, sure. But an all-out doctors’ strike is certainly a thought-provoking scenario. And an examination of the mere possibility provides some real insights into the problems our health care system faces today.
It’s tempting to see unionization as a way to radically alter the payment balance of power in favor of doctors, what with the huge sums of money flowing through the system. But a far better solution is to get the money out of third-party payers’ hands altogether and back into patients’ wallets.
Third-party payments — charges paid by people other than the two directly involved in the transaction — are what make American health care so inefficient. In the mid-20th century, patients paid doctors directly for 80 percent of their services. By 1980, that proportion had dropped to 40 percent. Today, a patient controls only 10 cents of every dollar a doctor earns.
As long as relatively disconnected third parties control 90 percent of doctors’ incomes, it’s unlikely that unionizing would do anything to restore doctor control or reinvigorate the “good ol’ days” of personalized doctor-patient relationships.
Organizing doctors presents a host of problems. Small groups of M.D.s have tried, but over the years, the federal government has prosecuted such attempts under antitrust law. Why the hostility to unionized doctors, when other skilled professionals like pilots, writers and teachers bargain collectively?
Doctors are uniquely critical. Illness, unlike travel or education, is not an optional activity. People can suffer and die, and the public outcry and panic over a medical strike would be politically intolerable.
Doctors also have leverage. They are literally “irreplaceable.” There are no temps who can fill in. What’s more, the licensing and liability constraints of today’s medical world would make the risks of dealing with a medical work stoppage unbearably high.
Further, how would a labor/management standoff play out? Most doctors operate within a fragmented business environment, working essentially as entrepreneurs. They’re paid by dozens of parties — insurance companies, government bureaucracies, health care complexes and, of course, individuals.
Who indeed is “management” in the medical field? Should all medical payers be consolidated into some kind of “industry association” that could be drawn to a union bargaining table?
Such a development is unlikely, if not absurd. A few idealists think the “solution” is to pass control of prices, supply and demand to federal bureaucrats. But then doctors would be paid less and would lose the professional independence and status they desire.
Unionization in the medical field has only worked when doctors found themselves in simple employer-employee relationships. A few doctors have unionized as interns or residents, and others collectively bargain with governments when they take on public-sector duties, as in prisons. In these cases, the employer-employee relationship, particularly with regard to payment, is well-defined.
The most obvious model for a straightforward, “doctor-as-employee” setup is the staff-model health maintenance organization, but that proved unpopular and unworkable with patients, doctors and payers alike.
Unionizing doctors is not the answer; giving control back to patients is. Let them choose and pay doctors without the bewildering array of bureaucratic intermediaries. The cost savings would be enormous, and doctors and patients alike would feel like they have control over their treatment.
The writers’ strike may have been a temporary inconvenience to our viewing habits and even taken some of our favorite fictional doctors off the air. But the mere thought of real-life doctors walking the picket lines, though unlikely, should compel policymakers to consider other options — like consumer-driven solutions — for moving away from our broken health care system of third-party payment.