Doctors and patients get burned by the world’s worst middleman.

In the first circle of Dante’s Hell, things aren’t so bad: The unbaptized and the virtuous pagans get to kick back, forever, with Homer and Ovid, watch Julius Caesar and Saladin do the limbo, etc. But things take a pretty sharp turn for the worse thereafter: Paris, Tristan, and Cleopatra get buffeted about by the winds of lust in the second circle, Cavalcante de’ Cavalcanti suffers a ghastly punishment for his heresy in the sixth, and soon enough you’ve got Satan himself gnawing on Brutus, Cassius, and Judas. But even with Virgil to guide him, Dante never looked into the little-known tenth circle of Hell, the joint headquarters of the federal health-care bureaucracies, i.e., Satan’s outhouse.


And if you think spending eternity submerged in a river of excrement sounds bad, try getting an appointment with a dermatologist. Dante had “Abandon Hope, All Ye Who Enter Here,” but we have “Please hold and your call will be answered in the order it was received.”

Researchers at JAMA Dermatology decided to do a little investigative journalism and cracked open the physicians’ directories for Medicare Advantage in twelve metropolitan areas. They invented a father with a suspicious itch, and started trying to make appointments. (Reuters provides an excellent summary of their findings here.) With 4,754 dermatologists to choose from, you’d think that would be pretty easy — and it’s lucky for you that there’s not a level of Hell for the naïve.


That population of 4,754 dermatologists turns out to have been decimated — about a tenth of them had moved on to one of the three sections of The Divine Comedy, or, short of that, had retired or were no longer practicing medicine. But the headcount has to be reduced further, and drastically: About half of the physicians were double-listed; unsurprisingly, the federal government is a much more attentive bookkeeper when it comes to your tax liabilities than it is when it comes to your health care. Another 18 percent were simply unreachable, and 9 percent were not taking new patients. Of those 4,754 theoretical dermatologists, there turned out to be 1,266 actual dermatologists still among the living, practicing medicine, and willing to make an appointment. But not for everybody: In some cases, there was not one dermatologist willing to see patients with certain Medicare Advantage plans. That’s what happens when you put politicians in charge of health care: You get a great deal on an insurance policy that no one accepts.

Earlier in the year, the Medical Group Management Association published the results of a very large survey (728 medical practices employing more than 40,000 doctors) on the effects of the so-called Affordable Care Act on real-world medical practices, and the results were terrifyingly predictable. Physicians do not much like ACA insurance plans, and not only because they tend to reimburse doctors at a relatively low rate. Because the people who control our nuclear arsenal cannot figure out how to operate a website or write an elementary English sentence, a great many people who bought plans through the ACA exchanges are pretty foggy as to what their benefits are, and end up being surprised by how high their deductibles and copayments are. For small practices and independent physicians, that sort of thing ends up being a problem, because they have to put more time and resources into collecting bills than into practicing medicine. If you’re a one-man dental practice, you end up spending more time on billings than fillings, which is one of the reasons for the trend toward consolidation — it’s certainly not because people love interacting with faceless bureaucracies.



That being the case, physicians are keenly interested in whether the insurance cards being presented by their patients are connected to an ACA plan — and they can’t find out. Some 62 percent of doctors reported “moderate to extreme difficulty” in being able to determine for sure whether a patient’s plan is from one of the exchanges or is a traditional insurance product. “We are going to have to hire additional staff just to manage the insurance-verification process,” one said, while another characterized the situation as an “administrative nightmare.” Nearly 60 percent of doctors said they expected the ACA to have an unfavorable or very unfavorable impact on their practices. Expect those additional costs to be passed on to consumers in the form of higher prices or diminished quality of care.


Smaller paydays, bigger headaches: What, exactly, is the economic incentive for doctors to throw their doors open to patients with ACA plans? Unsurprisingly, nearly a quarter of medical practices said that they would not be participating in any ACA-exchange insurance plans, most of them citing concerns about assuming financial liabilities, collections burdens, and other financial risks. Of those practices that are taking exchange plans, 85 percent accept five or fewer plans.

On the one hand, Medicare patients have a hell of a time connecting with doctors. On the other side of the equation, doctors have a hell of a time dealing with the Obamacare bureaucracy. That is what happens when the government stands between doctors and patients in its role as the world’s least effective middleman.


There is almost nothing else in our economy that works that way. Everybody hates the cable companies, and not without good reason, but you can pretty quickly get an answer about what’s included in a package and what that package costs. You can go online and spec out a car down to the color of the dashboard trim and get an exact price, to the penny. Yes, health care is complicated, but so is telecommunication: How many satellites does your dermatologist operate? Even visits to auto mechanics, which can entail nasty financial surprises, are generally characterized by prices that are determined before the work is done. It would be absurd to go into an Apple store and walk out with an iPad on the understanding that two weeks later you’ll get a 40-page bill in the mail that might be for one amount — or for ten times that amount.

It is inexplicable that the most important work — especially health care and education — is entrusted to the least competent institutions and processes we have. Nobody would stand for a public-sector monopoly on PlayStation games or a “Choose Your Own Adventure” approach to pricing sneakers. But we accept that for educating our children and treating cancer — for the things that matter most.


And what’s at the bottom of that pit of despair? Not any entity so colorful as Dante’s Satan or Milton’s, but a drab little coven of grey bureaucrats, mindlessly gnawing on the American health-care system, forever — or at least until somebody does something about it.

— Kevin D. Williamson is National Review’s roving correspondent and the author of The End Is Near and It’s Going to Be Awesome.