(This is the final part of the series. I'll return to lighter topics soon enough.)So what do we do about the struggling families who can't afford insurance, who don't want to pay for insurance, or who have chronic illnesses that effectively disqualify them from insurance plans? We definitely need a safety net for these folks. If we as a society are willing to pay for the care of the totally disabled, then we should be willing to support the working class when they need a little bit of help too. But as the brilliant Bill Whittle once wrote,
"I’m all for a safety net. It’s the safety hammock I have a problem with."I think it's important to try to keep health insurance affordable via sensible but not overbearing insurance reforms, so that the healthier segment of the "struggling family" group can purchase private insurance if they choose to pay for a higher tier of healthcare. The sicker or lower-income members of this group should probably be covered by state or federal assistance programs instead. These folks don't need "insurance" anyway...they need someone else to pay their medical bills for them. They are the ones who need government handouts, not the rest of us, so I am against any plan that would force healthcare rationing on the population at large. And to answer a previous question by Ms. Alison Cummins, this same safety net (and the lower tier of care it represents) applies to the previously healthy/insured patient who because of financial or medical disaster finds himself unable to afford the higher tier of medical care he previously enjoyed.
Providing the careWhy not increase indigent medical access by increasing the role (and perhaps the number) of our outstanding medical training programs? We can expand the services provided by medical students and residents at the state and county level, using a
sliding scale for charges based upon income. In my experience, indigent patients are typically appreciative of the relatively inexpensive and compassionate care provided by medical trainees. Insured patients, on the other hand, occasionally disdain such treatment. Despite the perception of a lower tier, the quality of care that is provided by housestaff and supervised by teaching physicians is often superior to that offered in private facilities. It surely isn't as convenient, but convenience is something you
pay extra for.
I suggest that community indigent clinics could also be staffed on a rotating basis by physicians who have been disciplined by their state medical boards as a retribution for various medical misbehaviors. Volunteer physicians might also staff such clinics if they were offered some sort of tax writeoff and malpractice protection.
The additional cost to patientsAccess to discounted rates for medical services do not come without a cost to the relatively indigent but able-bodied individuals. They should have to make some sacrifices in order to obtain their bargain medical care. They will have to pay their dues by allowing themselves to be on the teaching service, to obtain primary care by less-experienced (but supervised) physicians, and to accept the
possibility likelihood of increased waiting times, fewer clinic locations, and decreased availability of expensive therapies. They may be able to obtain certain more expensive services or medications by participating in research studies coordinated by the teaching hospitals.
Funding for these programs should be primarily the responsibility of the individual statesI suggest that each state should be primarily responsible for funding their own indigent and preventive medicine programs as they see fit, perhaps with some limited federal assistance or incentives. In Texas we fund our programs with sales taxes and property taxes, and we still don't have a state income tax. Teaching hospitals should establish or expand programs which send medical students and residents to satellite facilities in their state for clinical rotations. That would provide better access of care to uninsured patients, enhance the educational experience of budding physicians, and perhaps increase student interest in primary care. Expanding the concept of student loan deferment for physicians who agree to practice in these rural communities for a given period of time might be a good idea too.
EMTALA - follow the original intentAcceptance of transfers of stabilized indigent patients who present to community hospitals should be expedited by state/county facilities so that definitive care can be provided by the funded teaching hospitals. If EMTALA is going to remain the law of the land, then the original concept should be followed rather than the tar baby into which it has evolved.
Tort reform can increase access and reduce costs(edited for clarity)
One of the biggest crises in America today is the increasing difficulty of obtaining emergency surgical specialty care. Neurosurgeons, Orthopedists, Ophthalmologists, and Plastic Surgeons, for example, are avoiding ER call by giving up their hospital privileges to practice in free-standing surgical centers, leaving trauma patients in some areas with limited access to critically important services.Optimally, the provision of free medical care
(edit: such as that provided under EMTALA) should operate under the protection of Good Samaritan laws, thereby eliminating the prospect of malpractice torts and the extra associated costs of defensive medicine. If a patient is receiving free medical care, why in the heck should he be allowed to sue for a bad outcome? I think more
(specialist) physicians would be willing to provide unreimbursed
(emergency) treatment if they were immune from lawsuits. Alternatively, incentives to provide uncompensated medical care could be given to physicians by allowing them to write off the costs of their unpaid services as charitable donations.
"Self pay" patients should also be able to barter for discounted
emergency or nonemergency care if they agree to sign a waiver releasing the treating physician from malpractice liability, or perhaps limiting the scope of such liability. With the current system, the patient is forced to pay for maximum liability protection for each and every encounter. High risk patients, therefore, often find it difficult to obtain medical treatment. Allowing more flexibility in this area is another potential way to reduce cost and increase access to medical services.
The trauma fundFinally, a catastrophic medical fund should be established to help pay for uncompensated trauma care.
And I would suggest that this money should be distributed by each state wherever it is needed most, such as a rural EMS system, an inner city trauma center, a LifeFlight program, or even to build additional county medical facilities. This could be partially funded by additional levies on automobile sales, drivers licensing, automobile registration, gasoline, traffic violations or various misdemeanors and felonies. Other options include specific taxes on the sales of motorcycles, skateboards, or rock-climbing equipment to name a few only partially tongue-in-cheek suggestions. The most outstanding trauma surgery residents I've had the pleasure to work with all went on to make a living doing more lucrative lower-risk elective surgeries such as bariatric procedures and laparoscopic fundoplications. If we don't provide incentives to do the dirty work, not enough capable specialists are going to be around to do it.
ConclusionI believe that my plan would make healthcare more accessible to Medicare patients while increasing the efficiency of the Medicare and Medicaid programs. It might decrease the cost of insurance to make it more accessible to the middle class while still maintaining the benefits of the current system for the insured. And I suggest that it would provide increased access to care of the uninsured. What more could you want from a healthcare plan?
Now I can badmouth
Hillarycare Obamacare to my hearts content without anyone asking me snidely, "well what's
your plan then?"
Here it is...take it or leave it.