Malpractice insurance premiums rose, which was passed on to patients, and doctors were driven out by those high rates, or from burning out trying to see more patients than they could properly care for. Basically this creates a self perpetuated cycle, which has been incredibly difficult to stem because because there is a fundamental lack of capacity to increase the supply of doctors because there aren't enough doctors to supervise future doctors through their residency. Oh and certificate of need laws (CON laws, if ever there was such a proper letter word thing I can't remember the name of) where hospitals and related providers get to determine if a competitor should be allowed to enter the market.

I applaud your thorough response and acknowledge that you bring up some very good points. One concern I had, is that you kind of gave doctors an excuse and a pass on malpractice. Yes, if your workload is overwhelming, you’re going to make mistakes. But also there are just bad doctors out there filled with greed and/or arrogance who are using the system to work for them. (Important: not all of them. Lots of good practicing doctors out there.) But the American Healthcare system is also set up to favor the greedy. It’s a constant battle between physicians seeing patients and physicians in the government and on the insurers side arguing over what’s medically necessary, with both sides accusing the other of greed. The frontline docs just happen to get better press. I think we also have to acknowledge the climate we have where our culture is lawsuit-happy. Not just in medicine but in all facets of our cultures. This bled into medicine as well. Overall, great insight!

To be sure I didn't mean to imply that doctors, or that is the AMA and other professional and licensing boards, are deserving of a pass. They created the original imbalance, and they often battle solid solutions to fixing the provider shortage, such as increased independence of nurse practitioners, midwives, and developing a junior doctor program like the UK, and making it easier for doctors from other countries practice here. The first push to regulate abortion came from the male only gynecologist wanting the market share that was dominated by female midwives. Bad doctors and litigious lawyers are a given, but less of a driver than protectionist regulations. Tort reform does little to fix fundamental flaws which hurt the quality of care patients receive and the rising costs of doing business for providers. This also contributes to the lack of access to care in more sparsely populated areas, as it cost too much to set up shop independently, especially in underinsured populations.

Around the same time we created Medicare/ Medicaid, we also set policies to limit raising wages, to stem the inflation after the end of WWII. This left employers and unions with limited negotiation room, so the wretched employer based health insurance was born. And you can see on a graph how the costs of health insurance rising intersects with wages and subsequent stagflation of wages. This also led to opacity in actual medical costs to the average person, as focus shifted to premiums. Insurance became a significant provider of employment, and medical billing became another expense for providers. Providers entered into contracts with insurers that allowed them to hedge losses from uninsured, and lower paying insurers like Medicaid, by raising prices. And insurers responded by creating awful HMO plans, and a ton of bureaucracy.

When Trump said nobody knew how complicated health insurance is, I laughed, and laughed, and laughed, and laughed until I cried. His total disaster in handling the pandemic, which he shares with most, not all, but most of Republican leaders, is absolutely going to drive up the cost faster than inflation, and the quality of care down as we lose providers to infection and burn out.