ObamaCare Opponents Are Trying to Scare Young Adults

According to the most recent CNBC poll, if you ask people their feelings about “ObamaCare” you get different results than if you ask them about the “Affordable Care Act.” Namely, it seems that the use of “ObamaCare” is more polarizing. Asked about the Affordable Care Act, 22% of respondents reported a positive feeling, while 37% reported a negative feeling, and 41% reported being neutral or not knowing enough to have an opinion. By contrast, when you affix the President’s name to the law, there are fewer undecideds. Some 29% of those polled had a positive feeling towards ObamaCare, while 46% had a negative feeling towards ObamaCare, and 25% were either neutral or didn’t know enough to have an opinion. Somehow, that simple name change was all it took to inform them. But that’s not stopping opponents of ObamaCare from attempting to woo more of the public into their corner, and young adults are the latest target.

Healthy young adults are one of the groups that potentially lose out with the implementation of ObamaCare. The reason, of course, is that because of the individual mandate, many of these individuals who feel that they don’t need health insurance are going to be compelled to buy it or pay a penalty to the IRS. Either way, from their perspective, they are trading the option of spending nothing on health care to spending something. Arguments that they will benefit later in life, or that they just never know when they may end up seriously ill and in need of health insurance remain unconvincing to this demographic. On that latter point, this incredibly powerful narrative from Brian Beutler about how health insurance just might save your life–or at least save you from bankruptcy–is worth reading.

But the real menace is the notion of government intrusion in health care. The phrase “socialized medicine” has been misused for decades in an attempt to scare the public away from everything from national health insurance to Medicare, with obviously varying degrees of success. Now, a group called “Generation Opportunity” is using horrifying videos to scare young people away from ObamaCare, encouraging them to opt-out. They’ve made one for women and one for men:

There are a couple of major problems with their sales pitch. First, the insinuation that “Uncle Sam” (i.e., the government) is going to somehow be playing doctor is just blatantly untrue. Under ObamaCare, the insurance products people will purchase through the exchanges are private, and the doctors they will go to are also private. Government will not be telling your physician what he or she can or can’t do, and government certainly won’t be directly providing your health care. Second, “opting-out” is likely to cost young people more, not less. The reason? Individual coverage not obtained through the exchange is typically not good coverage. So, this campaign is effectively telling young people to pay a penalty to the IRS on top of paying for a less expensive, but also inferior insurance product on the individual market. Then, if they do end up needing health care, they’re likely to end up paying substantially higher amounts out-of-pocket for that care. For most young adults, this makes little sense. First, ObamaCare allows them to stay on a parent’s plan until age 26. After that, they will most likely have very affordable insurance options through their own employer. If not, they will have the option to get high-quality coverage through the exchange, and with federal subsidies, the cost of that coverage is likely to be rather low as actual data is demonstrating. Ultimately, this campaign seems like an effort to undermine the health insurance exchanges and diminish the effectiveness of ObamaCare, but you shouldn’t have to scare people to get them to agree with you.

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Wonk Review Out: And Wright on Health Is Featured…

Peggy Salvatore of the Healthcare Talent Transformation blog has posted an excellent edition of the Health Wonk Review. Why is it excellent? Well, one reason is because it is entitled “The 700th Anniversary Blog Question Is….Will a Government Shutdown Stop ObamaCare,” which is a reference to my recent post on the subject, which happened to be Wright on Health’s 700th blog post. That’s a lot of writing folks! To help us celebrate, read the Health Wonk Review here, and tell others about Wright on Health through email, Facebook, and Twitter. We have 701 posts now, and we’d love to get 701 hits or more every day!

 

Can the “Government Shutdown” Shut Down ObamaCare?

The federal fiscal year begins October 1st. That’s the date by which, if Congress fails to pass a budget that the President can sign into law, the federal government will shut down. There are a number of implications to such a shutdown. For example, national parks and monuments will be closed, and nearly all federal employees will be sent home on furlough. The military will continue to operate, but its personnel will be paid in IOUs. Likewise, “critical” jobs like air-traffic control will continue, but if you need to renew your passport before leaving the country, sit tight: The U.S. Passport Agency won’t be making much progress during a shutdown. But what about ObamaCare? How would a government shutdown affect the implementation of this sweeping reform of the health care system?

The answer, it seems, is not so much. The primary reason is that much of the funding for provisions of the law are not subject to annual appropriations, and are therefore able to continue operating even without Congressional budget approval. There are other details, of course, and Sharon Begley and Lewis Krauskopf summarize them nicely here.

The irony is that the GOP intended to disrupt the implementation of ObamaCare by passing a budget that stripped away funding for health reform. However, because the Democratically-controlled Senate is highly unlikely to approve such a bill, and the President is even less likely to sign such a bill into law, that decision is what is leading us down the road to a government shutdown. A shutdown that, in all likelihood, will have very little effect on ObamaCare implementation. It’s even more ironic when you consider that October 1 is the date that the health insurance exchanges–a central element of reform–are expected to begin enrolling people for coverage effective January 1, 2014. This explains why the President is hitting the road to educate the public about the exchanges and encourage them to get enrolled. October 1 could be a rather monumental day in its own right. Thankfully, it’s not the kind of monument that can be shut down by the federal government.

 

Lasting Effects: Health Impact On First Responders

September 14

The days after September 11^th, 2001, the city of New York was enveloped in a blanket of ash. Rescue workers spent hours, days, even months without rest sorting through rubble and dust, exposing themselves to all kinds of physical dangers. These images are well documented in newspapers, television images and museums. But the haunting images from the aftermath, including the one of firemen I keep in my kitchen, do not tell the ongoing story of the men and women who risked their lives, physical health and mental health to dig the magnificent city out of the ash.

Despite the immediate coverage of heroism for the country’s rescue workers, very few have taken time in the last 12 years to fully research the physical and mental toll taken on those individuals that risked their lives on September 12^thand the following days. According to the City’s Department of Mental and Physical Hygiene “thousands of individuals—including rescue, recovery and cleanup workers and people who lived, worked or went to school in Lower Manhattan on September 11^th—have developed chronic, and often co-occurring, mental and physical health conditions.”

Understanding The Impact

Most of what is known about the issues affecting thousands of domestic and international rescuers has been collected by the New York City HealthDepartment’s World Trade Center Health Registry. This Registry, which allows health professionals to track and investigate illnesses and recovery related to September 11^th also helps create guidelines that can save lives and reduce injuries in future disasters.Dr. Robert Gillio, who is significantly responsible for its creation claims that, “The Registry was not part of any preplanning. Nor was the care of the New York Police Department (NYPD) or construction volunteers. I got a panicked call from someone that knew I had developed a middle school lab kit enabled laptop with curricula for how to measure heart and lung function and learn how to protect them. It was something I created for my four daughters to make health and science education more interesting.”

Following that creation, Dr. Gillio says, “When I joined up with a team of volunteers screening NYPD officers, this early telemedicine app was used to create health records. We had the presence of mind to realize the vast differences in the levels of exposure and decided to create questionnaires for what is called risk stratification.”

From that point forward the Registry has providedguidelines for domestic and international health care providers to care for those who volunteered in the aftermath of September 11^th by creating flow charts, tracking systems and symptom coordination for individuals who may be experiencing conditions related to World Trade Center exposures. The database has collected information on more than 70,000 people over a decade and includes not just the official heroes of September 2001, the NYPD and the Fire Department of New York (FDNY), but also the volunteer and paid professionals that tended to health care at the site, search and rescue teams, demolition and hauling teams, those who cleaned apartments and residents that moved back into the neighborhoods.

First Responders

All of these individuals took health-related risks, risks that are hard for many of us to understand, but none more so than the first responders. I certainly would not be one to run straight into the face of danger, despite that being in my genes. Growing up in a family of firemen meant that we came to terms early on that loved ones would risk their lives to save others. However, the honor and pride these men have shown throughout our lives often leaves us in fear. My admiration for my Father’s inherent need to help others gave way at times to fears of losing my hero to saving the lives of others buried in ashes. When asked why he chose to become a fireman, my dad, Rodney Fender, humbly said, “It’s just who I am. I want to help people.” He went on to describe the feeling that overcame him as a fireman, the one to rush into danger, saying his logical reaction to the call was, “How the hell do I get in there, and how do I get them out safely.” His immediate response has never been to think about himself above others.

When asked about this innate desire to risk oneself, it became clear that my father, like many rescuers simply react in a way that brings out the best in human nature. A mentality of our heroes following September 11^th, who were still there working through the ash and rubble, was best summed up by my grandfather, Michael Fender, also a fireman who said, “It’s just your job as a person to help other people.” He went on to explain that first responders have a mindset like his, “You do what you can, when you can, how you can. That’s just how we work.”

Lifelong Effects

September 11^th was a day that changed American lives forever, one that shook our faith in humanity to its core. Like all US Citizens, mental health and safety were altered in significant ways during that time of fear. For the rescue workers though, the risks of danger did not end with the last plane crash or the decision to go to war. For the first responders, volunteers and health care professionals and researchers, September 12^th marked another day to face physical and mental health risks to save the lives of others.

The image of an ash covered park in New York City with firemen working tirelessly in the background has been in my kitchen for many years, and serves as a daily reminder to the resiliency of this country, its citizens, and especially its heroes. Although their images are almost invisible in that photograph due to the devastation surrounding them, they are there, digging the city out of the rubble and piecing the lives of others back together.

In a similar vein, Dr. Gillio sat down soon after the attacks to write Lessons Learned at Ground Zero, an essay to, “Help explain to my daughters why mom and dad were away at Ground Zero when planes were falling out of the sky near us in PA. That book found its way to the White House and lead to a request for participation in a series of discussions there regarding the role of the average person or local organization in disaster preparedness, response and recovery. Those lessons in 2001 changed my career from one that treated preventable disease to one that finds ways to discover who is at risk and to intervene to prevent a chronic disease or acute injury and to empower the individual to be the health hero for themselves and their community.”

His message, and that of my father and grandfather, is correct. The terrorist attacks in 2001 changed American life forever. But as health care experts, providers, researchers, policymakers and first responders, it is our duty to take the lessons we learned from those horrific days, weeks and months to build a better system of care. Our job is to use our skills and passions to improve our communities as a whole and prevent, as well as care for, one another as best we can.

For more information, the 2009 World Trade Center Health Registry Report and Findings can be found here: WTCHR.

 

Latest Health Wonk Review at Boston Health News

Twice a month—sometimes more—you get the opportunity to go to one place and read the best of the health policy blogosphere. Today is one of those days. So head on over to Boston Health News for the latest Health Wonk Review and see what a great job Tinker Ready did!

 

What Will You Pay for Insurance Under ObamaCare?

Since it was first debated, one of the major criticisms of ObamaCare was that it was going to make the cost of health insurance skyrocket. And, in turn, many critics of the law who happen to own their own businesses, expressed concern that they would be forced to pass on these higher costs to their consumers. We were told that Papa John’s large pizzas would cost an additional 14 cents because of higher insurance premiums. Consequently, Papa John’s and Applebees—whose CEO is also an outspoken critic of ObamaCare—have seen the public’s opinion of them drop dramatically. Of course, the White House released numbers to dispute the notion that employers would be hiring fewer full-time employees to avoid paying for their health insurance. But the best news of all is that we can stop speculating about what will happen to insurance premiums under ObamaCare, and start looking at actual data.

This is precisely what the non-partisan Kaiser Family Foundation did in a recently released report on 2014 health insurance premiums in 17 states and the District of Columbia. What they found is that health insurance premiums aren’t that high. In fact, they are lower than the Congressional Budget Office projected that they would be. Of course, that doesn’t mean that rates won’t have increased from the year before, as Avik Roy points out in arguing things from the consumer perspective. But Roy also oversimplifies things, because he fails to take into account the net cost to the consumer in light of the fact that many–if not most–Americans, will receive federal subsidies to help them purchase coverage. On this point, Wonkblog’s Sarah Kliff does a terrific job of walking through different scenarios, based on an individual’s age, income level, and choice of insurance plan, to calculate actual monthly premiums in 2014 after the subsidies are taken into account. The news is generally quite good: A 40-year old woman in Seattle earning $28,725 a year will receive a $90 monthly subsidy, which means she can get a silver plan for $193 a month or a bronze plan for $123 a month. As insurance goes, that’s awfully inexpensive. And, Kliff points out, if the same individual was 60-years old, she’d effectively get an even bigger subsidy, worth $408 a month, so that she can get a silver plan for the same $193 a month, but would be able to get a bronze plan for just $44 per month. Folks, that’s $528 a year for health insurance with a 60% actuarial value.

These rates are low, and by October 1, we should have actual premium pricing for all 50 states, so more analyses like these can be done, and we can start outreach and enrollment efforts to educate people about their options and what various insurance products available in their state will cost them. What we won’t exactly know–a point Kliff makes in her own piece–is what people are willing to pay or what they consider “affordable” as the Affordable Care Act has implied care will be. This is more subjective, because it depends on how people prioritize their health, and thus their demand for health insurance, and how they budget the rest of their income. Overall, though, the early news seems positive, and suggests that for many people, affordable health insurance–and the health care it buys–is just a few months away.

 

Say Hi To Oscar: The New Company that May Change Health Insurance

In five weeks from now, the Patient Protection and Affordable Care Act (ACA) mandates the opening of health insurance exchanges around the country. At that time New Yorkers will be introduced to an innovative way of thinking about health care: Oscar. Three friends, and technology entrepreneurs, teamed up to do something that has been inconceivable to date—create a start-up health insurance company to take on conventional health insurers on the NY exchange. Oscar co-founders, Josh Kushner, Kevin Nazemi and Mario Schlosser, plan to change the health insurance industry through technological interfaces, telemedicine and real transparency. Their goal is to redesign insurance to be geared toward the user experience, to make patients seek out their insurer before their doctor.

Americans do not usually think of health insurance as an intimate part of the care process. When sick, individuals do not call their insurance company for care or support. The health insurance industry is considered confusing, at best. The ACA however, presents an opportunity for the reformation of health insurance as we know it, not because of its disappearance, but by making it an integral part of receiving quality care. According to one co-founder, “We want consumers to feel like they have a doctor in the family.” That family doctor he speaks of is Oscar.

Oscar will have one plan in each of the ACAs metal-tiered categories, and additional plan options for the Bronze and Silver tiers. Although Oscar will have some of the familiar pillars of the health care industry like co-pays and deductibles for in-person visits, it introduces new elements like free telemedicine, free generic drugs and online price comparisons. Oscar health insurance will pioneer “a consumer experience, not a processor of claims,” explained Nazemi, with the goal of simply guiding individuals through the complex health system in an integrative and safe way.

Customer Service: What Oscar Can Do For You

Through user experience, customer service and innovative care options, Oscar will attempt to expand the role of the health insurance company to a health services provider. Oscar is being developed not just to cover medical costs, but to be the primary place to get the medical assistance a patient needs at any time.

When Oscar opens on the New York insurance exchange on October 1^st, there will be a focus on function, ease of use and design. When a patient logs into HiOscar.com, he or she will want to keep using it like a new iPhone or laptop, or so the creators hope.

For frequent conditions or issues, patients will be able to find treatments right on the website and have 24/7 access to a physician through their unique partnership with the telemedicine company, TeleDoc. Additionally, the creators claim there will be no need to discuss prescription refills in-person with an expensive physician when a user can have “one-click refills” through a health records feed that resembles a Twitter timeline.

Oscar will also offer services at many hospitals and retail locations such as New York CVS CareMark. The partnership that Oscar and CVS have is so strong that CVS is building sites for Oscar. These added locations will serve as one method of addressing the physician deserts that exist in the state. The company also contends that Value Options is a strategic partner with the goal of making mental and behavioral health care more accessible for the newly insured.

Not everything will be brand new though. Oscar will offer several types of plans like traditional insurance companies, but the approach is slightly different. As Schlosser explains, “packages will be bundled like AT&T, which consumers are now accustomed to.” The intention is to eliminate many of the arcane rules of the insurance industry, which often frustrate patients and erode the customer service experience.

Schlosser tells a story of him, his wife and baby going to CVS in the fall of 2012 to get flu shots in New York City. Schlosser gets his shot, but when his wife goes for hers, she is rejected. The pharmacist explains that Mario’s insurance only covered one shot per 24 hours. Schlosser, who at the time was already working with Kushner and Nazemi on Oscar, explained that Oscar is designed specifically not to have such “Byzantine rules.”

Telemedicine: The Doctor Will See You Now

When describing key functions of their new company, Nazemi and Schlosser emphasize that telemedicine will be the method by which many of their objectives are accomplished. Although telemedicine has been around for a while, it has not been wildly popular with patients to date. Oscar hopes to change that feeling with new incentives, 24-hour online services and a sleek design.

The founders of Oscar claim that consumers will have access to a doctor by phone within 20 minutes of a request, with no co-pay. Perhaps the concept is not revolutionary, but if it works, the behavioral changes associated with seeking care could be seismic. Currently, not many patients log onto insurance carrier webpages before seeing a doctor, unless they are seeing if the doctor is in-network. Oscar, however, wants patients to start their care with the insurer, not just use it for payment submission.

Oscar also plans to have incentive programs such as the “10 for 10,” where patients will receive $10 for answering 10 questions about their health and preferences. The answers from those questions will then be used to establish proactive health care, as well as help the Oscar team make continual upgrades based on user preferences. For example, answers to the “10 for 10” might help create an outreach program for Diabetes patients where a registered nurse would come to the home, or the answers might inform web developers on how utilization could change in the future.

For added flexibility, Oscar asserts it will employ registered nurses and nurse practitioners to provide in-home follow-up services for patients if needed. In the case of new mothers, weekly visits to the home can be arranged if that is preferred over online interaction. Schlosser described his vision of this component as “integrating backwards,” where patients and providers interact in the settings they choose at the times they agree upon.

According to the creators, in addition to the partnership with TeleDoc, Oscar has already amassed some form of relationship with more than 83 hospitals in New York, hoping to make the telehealth to in-person relationship seamless.

Just How Transparent?

Transparency, the newest buzzword associated with the ACA, plays a dual role in the Oscar story. The availability of data drove Oscar’s operation and consumer focus, and has been an integral part of their ability to test their interface with government feedback. Schlosser describes tracking and analyzing years of medical claim data for entire episodes of care to help assess how technology and telemedicine may better treat patients. His go-to example relates to how many people use expensive physician time and technology for simple ailments like headaches, where large percentages of costs go to small percentages of patients.

Data analysis like Schlosser describes are only the beginning. As more medical data becomes available under the ACA, more and more relevant analyses will be conducted. The Oscar team is counting on this improved data to help them meet patient needs on the platform as well as potentially predict future health demands. Like their past Instagram endeavor, the group hopes to make data the backbone of sharing information.

Oscar’s creators were quick to stress that design and functionality are also deeply rooted in transparency. Schlosser explains that the interface will allow consumers to see price differences based on location, facility and desired services.

On Oscar, a user will supposedly be able to look up prices for doctors across the street from one another or shop for MRI pricing by facility. Schlosser boasts that patients will be able to view “heat maps of services and providers.” The question, however, of whether patients will actually log on to compare prices remains unanswered. Human behavior indicates that unless cost savings are passed on to the consumer, there is very little incentive to look for or care about alternatives.

Media Experts As Marketers

Oscar’s founders plan to target all uninsured in their market area. Based on Oscar’s innovative approach to insurance, and the creator’s unique backgrounds in social media, the marketing endeavor will surely be novel. Nazemi says that the approach to courting the uninsured will “include traditional and nontraditional forms of media,” with the ultimate goal being, “to win over every consumer.” This winning of the consumer, or patient, will include all of the feedback mechanisms and personal interaction that allow for real time updates to the company.

Although Oscar will be targeting the entire uninsured population in their New York market, it is likely that the young, healthy and social media savvy will be the easiest to penetrate with marketing materials. This population, however, has been of the greatest concern for the constructors of the ACA, and the reason the individual mandate exists. As time progresses we will see how Oscar uses its flexibility to attract and maintain a young and healthy population that is the least likely to pay for insurance.

Currently, the Oscar site is merely a welcome page and a list of open positions within the company. But, on October 1^st, the site will be fully functioning, possibly putting other sites and insurers to shame. It is certain, given its creative employee background, that the feel and design of Oscar will be more user friendly than the state-based or federal sites.

According to Schlosser, the idea for consumer usage is to have a site where, “like Google, you can come use Oscar. You can type in your issue and we will help you find the best solution.” He explained that the entire experience will be interactive.

When asked about their role or faith in the success of the ACA, the team commented that, “the ACA is a catalyst for what we’re doing.” And the creators hope that Oscar will become a catalyst for the rest of the health insurance industry to be more transparent. They claim Oscar will set the stage for new expectations and behaviors by consumers, and that people already know they deserve more from their health care system.

Whatever the success of Oscar in the early stages of the exchange market in New York, one thing is for certain; Oscar has the potential to cause much needed disruption to health insurance and health care.

You can say hello to Oscar at HiOscar.com

 

Primary Care Deserts Do Not Disappear With Nurse Practitioners

In coming years the US could see growing shortages in the availability of primary care physicians (PCPs). With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.

While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted. The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are complements, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.

Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.

The US, unlike many western countries, does not actively regulate the number, type, or geographic distribution of its health workforce, deferring to market forces instead. Those market forces, however, are paired with a payment system whose incentives favor high volume, high return services rather than health or outcomes. These incentives are reflected in where hospitals steer funding for training, and in the outputs of that training.

Throughout the US there are geographic pockets that fail to attract medical professionals of all kinds, creating true primary care deserts. These deserts occur in part due to the unequal distribution of practitioners in the health care system, with our medical schools and salary opportunities producing low numbers of generalists across the board. We have even continued to see shortages in nurses throughout the US.

In fact, 2012 residency matching rates not only show continued unfilled positions in primary care, but that the rates of graduating minorities are highly skewed from programs. This contributes to even greater problems with finding primary care providers that reflect the populations they serve. Sadly, this is also true for nurse practitioners, where only 4.9% are African American, 3.7% are Asian or Pacific Islander and 2% are Hispanic. Further, the geographic distribution of NPs and physicians assistants alike is close to that of physicians. A June 2013 assessment found that the distribution for urban, rural and isolated rural frontier primary care providers is within a few percentage points for NPs and PCPs.

Ezra Klein was not wrong in his assessment that physicians are often influenced by income. However, it seems likely that financial incentives are drivers for many professionals in the health care sector, including nurse practitioners, registered nurses and physicians assistants (PAs). Dr. Andrew Bazemore, Director of the Robert Graham Center for Policy Studies in Primary Care in Washington, DC has done significant research in this area. His perspective is that, “The suggestion that runaway health system costs could be contained simply by replacing higher salaries of physicians for lower salaried substitutes with less training misses the point – that cost containment will most likely result from optimizing primary care functions such as prevention, population management, care coordination, and avoidance of unnecessary referrals, procedures, ER use and hospitalizations of primary care providers.” Dr. Bazemore asserts that, “Achieving that level of effectiveness likely involves teams that include primary care physicians, NPs, PAs, behavioral and community health workers, and other important components, operating in a transformed practice setting.”

It is also correct that regulation on NPs is onerous and sometimes oppressive. Across the nation, regulation on NPs is exceptionally disjointed and often results in unnecessary hurdles for all involved, called scope-of-practice laws. Although impediments are common in the health care system, it is extensively difficult for NPs and similar non-physicians to break into a system that is deeply rooted in tradition.

However, by honing in on one piece of the puzzle, Mr. Klein missed the bigger picture. The principals of substitution do indicate that on the supply side, NPs stepping into roles for PCPs would better meet demand. But that is not the real world outcome. The broader landscape shows us that instead of a 1:1 substitution, nurse practitioners are compliments in the overall care system, important roles that fulfill many primary care needs.

Therefore, policy changes are still needed to improve patient health outcomes and forge a team-based relationship between care providers. Incentives to enter primary care and needed across the disciplines, as are models of team-based training that build on the strengths of each in managing whole persons and populations. Ezra Klein fails to note that most primary care shortage estimates implicitly include NPs and PAs already working in primary care while not accounting for the fact that NPs and PAs are choosing specialization over primary care for the same reasons as physicians.

Instead of an environment where NPs and PCPs are positioned to compete with one another, federal and state legislators should spend more time crafting policy that equalizes the distribution of care providers across the system. That redistribution means incentivizing, monetarily or otherwise, primary care clinicians to stay in general medicine and work in tandem with other providers. Whether it be the reformation of medical school, constructing a more honest approach to population health or restructuring pay scales and incentives, team-based medicine with improved access and outcomes should be the real discussion.