The most serious threat to the successful implementation of the Affordable Care Act is probably its complexity. Yes, the basic idea of creating risk pools large enough to make universal access to private health insurance affordable isn’t that hard to grasp. What’s insanely complicated is the context within which this reform is taking place: the intersection of federal and state involvement in health care, which is different in every state; the interplay of Medicare and Medicaid and the new health care exchanges; the varying dynamics of group and individual insurance markets; the essential role of the tax system in making the bigger risk pools possible and in making the whole scheme affordable for its intended beneficiaries.

We’re experiencing this complexity in a particularly intense way because one of the two major political parties and its allied media are committed with the devotion of the cloistered to the identification and exaggeration of Obamacare implementation problems, even as they seek to create new problems and resist (successfully) any effort to fix existing problems.

But now and then, just occasionally, we glimpse a problem that’s reasonably straightforward, and that actually has little to do with the Affordable Care Act, but could affect its success or failure. Ezra Klein noted one today at Wonkblog: the efforts of physicians to maintain their monopoly on medical decisions and services that might be just as easily and far less expensively be performed by nurse practitioners:

17 states and the District of Columbia already allow nurse practitioners to treat patients directly and there’s been no resultant rash of patient deaths in Washington, Oregon, Maine, Colorado, Arizona, New Hampshire, Vermont, Rhode Island, Montana, Idaho, Nevada — I could go on. (Nor, by the way, has anyone heard of doctors going begging on the streets in those states, but I digress.)

The Wall Street Journal reports today that five other states are considering freeing nurse practitioners to practice with physician oversight, including California, where only 16 of the state’s 58 counties have enough primary-care doctors. These kinds of shortages are common, and they’re likely to get even worse as the population ages and the Affordable Care Act expands coverage to millions of Americans.

Doctors don’t have a good answer for how they can rapidly expand to meet all this new demand. But they know they don’t want nurse practitioners doing it. The powerful California Medical Association — also known as the doctor’s lobby — opposes the bill with the usual line: It will “ultimately harm patients and decrease quality of care.”
No, what will ultimately harm patients and decrease the quality of care are too few doctors who charge far too much. But right now, those doctors are the incumbents, and incumbents are politically powerful. They’ve persuaded the California state assembly to amend the bill so it “would allow NPs to operate independently only in a hospital, clinic or other group setting and eliminate a pathway to autonomous practice after 6,000 hours of supervised work.”

Ezra calls the system the doc lobby is defending a “protection racket.” That’s not an exaggeration, and it’s common in all the regulated professions where a limited supply of services can keep prices and incomes as high as is possible.

But in the complex and every-changing world of health care, it’s something that can be addressed directly, and will benefit Americans no matter what happens to the Affordable Care Act.

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Ed Kilgore is a political columnist for New York and managing editor at the Democratic Strategist website. He was a contributing writer at the Washington Monthly from January 2012 until November 2015, and was the principal contributor to the Political Animal blog.