The Metro's purpose, likewise, is to move people around our nation's Capitol. And it does so competently — within limits. But it doesn't do so cheaply, or very efficiently at peak hours, or with anything like comfort or customer service.
It can't. It's been pushed to its limits — and at rush hour, it's clear it's pushed past its limits — by demand. It's the nation's second busiest subway system, in the nation's 25th most populous city. There are physical limits to how much it can expand. The best the city can do, then, is attempt to reduce demand by limiting access.
In other words, the Metro's purpose is to provide transportation for its riders. Its function, all too often, is to put up roadblocks.
How? Let's start with the complicated fare system. If “fairness” is Washington's watchword these days, no one has informed Metro officials. Fares are structured not to be egalitarian, but to discourage riders from using the system during rush hours. Even the seven-day passes — the ones tourists buy when they're overwhelmed by the menus on the automated ticket machines — don't cover “peak hours.” Riders must pay an extra buck or so just to get out of the subway station if they've ridden during a rush.
There are other intentional impediments; the turnstiles slow the flow of riders, and when it gets too crowded, Metro workers put up barricades to prevent ticket-holders from even entering the stations.
And that's what the health care industry will be forced to do. Did anyone think that mandating coverage would do anything but increase demand on an already-overburdened system?
Let's put economics aside for the moment and simply look at access. The ACA increases coverage two ways: it says that if you can buy health insurance, you must (in many cases, through discounted state-wide exchanges); and it increases the Medicaid rolls to cover those who can't.
But we know that the U.S. has a severe doctor shortage.
“The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed,” the New York Times reports. “And that number will more than double by 2025, as the expansion of insurance coverage and the aging of baby boomers drive up demand for care. Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000.”
What's more, we know that more than half of all physicians have stopped accepting new Medicaid patients.
That means those increasingly scarce health care resources must be “managed,” just as access to those Metro trains is managed.
There are signs of rationing already. At least 15 states have put limits on how many prescriptions they'll fill for Medicaid patients.
“At the end of the day, we have to provide care, but we have to have a balanced budget,” one Alabama official said.
That's merely a sign of much more to come. There's little the ACA can do to increase supply — doctors take years to train, and they can't be drafted — so it must seek to reduce demand. Health care officials will spend more and more of their energy finding way to impede access.
And so they'll be like those Metro officials.
If Republicans win the White House, they may succeed in repealing the law. But they won't have done a thing to address the shortages we still face. They'd better be ready with a plan of their own.