Having trouble finding a doctor?
Medicare is to blame, and Medicare for All would only worsen it.
There are many reasons for the physician shortage, but burnout and early exits from clinical medicine are major drivers. These physicians who leave practice blame administrative hassle as a leading reason.
Medicare for All advocates claim that removing private insurance would alleviate this burden, allowing doctors to practice medicine again. This is a dangerous misconception, and I warn my fellow physicians not to be taken in by this siren’s song. Most of the micromanagement in the working life of physicians comes not from private insurance, but from Medicare.
Like most physicians, I deal with the administrative hassle imposed by private insurance: the prior authorization, the claims denials. But those are just a minuscule part of the problem. I spend more hours of my day glued to a computer to satisfy Medicare’s rules.
Medicare sets the “conditions of participation” for hospitals and payment rules for doctors. These regulations give administrators sovereignty over the practice of medicine. When Medicare is the major source of revenue, it is the primary customer, and its preferences must be given priority. For example, doctors’ concerns over non-working operating room equipment are ignored while administrators threaten them for not copy-pasting the correct checklist into their computerized notes. Medicare prioritizes the checklists more than the working operating room equipment. Administrators take up hours of clinicians’ time hounding them about documenting quality scores. Medicare prioritizes computerized data input over face-to-face patient care.
When Medicare pays a hospital, it relies on very specific documentation from the doctor. Does the patient meet inpatient criteria? What diagnosis category are they in? Do they have a “major complication or comorbidity”? This all relies on if certain words were in the physician notes. So hospitals hire teams of consultants to comb through patient charts, then harass the doctors to edit their notes, making sure the hospital maximizes billing.
Medicare’s quality metrics add even more demands. These schemes, intended to reward hospitals with the best outcomes, have become exercises in metric manipulation and coding games, again largely falling on the doctors. A 2016 study found physicians spent 2.6 hours a week on quality reporting. A study of heart-failure patients even linked a readmission-reduction program to increased mortality. MedPAC, which advises Congress on Medicare policy, recommended replacing many of the programs. Yet, Medicare continues them.
Physicians have also seen their independence vanish due to Medicare rules. In 2024, 57.5% of physicians were employees of large hospital systems, up from 41.8% in 2012. Adjusted for inflation in practice costs, Medicare physician payment has fallen 33% from 2001 to 2026, while the cost to operate a practice has gone up. Meanwhile, federal policy gives hospitals financial advantages, such as facility fees and 340B benefits, that are unavailable to independent practices. Thus, many doctors, unable to maintain their overhead costs, sell to hospitals who have these financial arbitrage opportunities.
Medicare also restricts physicians from building alternatives. Section 6001 of the Affordable Care Act bars new physician-owned hospitals from billing Medicare. Stark Law restricts physicians from referring Medicare patients to ancillary services they own, such as an MRI or physical therapy clinic. Medicare favors large, consolidated hospital systems over independent practices, steadily eroding physician autonomy.
So why would physicians want MORE of Medicare?
I can see the allure. After a particularly frustrating experience with private insurance, doctors might be excused for wanting to eliminate those complex middlemen with their utilization management rules. Indeed, Medicare for All supporters promise simpler billing. They promise they will get rid of the quality metrics, the declining reimbursement, and the complexity.
But this is not realistic. Healthcare utilization would increase under Medicare for All. The CBO predicts this. We have multiple randomized studies which show utilization goes up as patients’ out-of-pocket costs go down, and the increased utilization is in both less-effective and more-effective care. So, to reduce the use of that low-value care and keep from overwhelming the system there must be some sort of utilization management.
We ran this experiment in the early days of Medicare. The original rules for doctors had no modern quality metrics and far simpler coding and utilization controls. Doctors could bill Medicare based on their “customary” charges. Costs rose rapidly. Over the years, Medicare slowly added all the utilization control schemes outlined above. They implemented price controls. They cut reimbursement. They restricted doctors from self-referral. They added quality metrics.
Medicare for All might promise simplification and high reimbursement for doctors. It won’t deliver. Not without blowing an even bigger hole in the federal deficit. It’s an economic impossibility.
The answer for physician burnout and the resulting shortage is not going to be an expansion of Medicare. It’s going to be deregulation, allowing physician ownership and autonomy to once again flourish. Doctors are doing this outside the system right now, offering low-price and high-quality alternatives. Physician-owned hospitals have high patient-experience scores. Direct primary care doctors report high practice satisfaction. Cash-pay surgery centers are thriving.
Doctors working in these environments, outside Medicare, report huge reductions in compliance costs and office staff. They aren’t micromanaged by administrators. They aren’t glued to a computer instead of taking care of patients.
They’re just practicing medicine again.
Doctors need that to stay committed to clinical medicine. More Medicare would only make the doctor shortage worse.
