The Public Option

PRIMARY-CARE-MEDICINE

HEALTH CARE à la CARTE

For those under 65 and not too poor the current Health Care system leaves much that is desired. It is expensive, too many (perhaps 40 million) have no Medical Insurance, and those able to meet the costs find themselves caged in panels that deny them free choice of specialty medicine and surgery.  Therefore I envisioned changes that would significantly improve things without causing too much disruption. Namely to divide the current system into two components; HMO insurance for high tech and catastrophic illness, and a Single Payer System devoted to Primary Care Medicine that would be offered from offices scattered  all over the country available to patients 24/7/365.  

 It turns out that legislating a New Single Payer is no longer necessary because it exists--

while trying to disseminate my “plan” to government and others I discovered that under the American Recovery and Reinvestment Act President Obama had provided $500 million (some say more than that) to the “Primary Care Centers of America”.  Only then did I learn that the ingredients of this bicameral system have long existed, initiated by President Truman when he created the USPHS, and empowered by President Johnson in concert with Medicare and Medicaid to serve those with limited access to health care.

Thus for President Obama to find the seeds of a more satisfactory Health Care system he need look no further than the 8000 or more Primary Care Medical Centers free standing and entrepreneurial that are scattered throughout the country.  Except for a small number of private practices certified as Primary Health Care Centers, the vast majority are community based, funded by Government Grants administered by the Health Resources and Services Administration (HRSA) and managed by a Board of Directors drawn from their respective communities. These centers, uniformly staffed by specialists in Pediatrics, Primary Care,  Internal Medicine, Gynecology and Dentistry are available to provide integrated medical and dental services to the medically indigent as well as any other citizen, with fees adjusted according to the ability to pay. (for a complete description of the program and centers visit http://bphc.hrsa.gov/about/) 

 It is absolutely astonishing that so few of us seem to know about them. However, were they to be expanded and modified to serve communities 7/24/365 these Medical Centers would form the crux of a Health care system that would be much healthier than the current one.  

The present Health Care System is comprised of two sectors: one Public (Medicare, Medicaid, Veterans, U.S. Public Health Service) funded and managed by the  federal  government; and one private in which individuals can buy medical insurance from any of an array of Health Maintenance Organizations (HMOs). The public sector is well accepted but the private sector breeds discontent, mainly due to prohibitive direct costs that leave 40-50 millions of Americans without any Medical Insurance, although low cost primary medical care is available (to citizens only) at the Primary Medical Care Centers of America. 

I have long advocated that a first step in dealing with the problem would be to cut the baby in half, separate Primary Care from private HMO coverage. The HMOs would continue to insure for High Tech, Consultative and Surgical services as they do now, but no longer will be mandated to cover Primary Care medicine.  By expanding Primary Care Centers, Primary Care Medicine would henceforth be covered by Community based Primary Care Centers as described above.  Thus there will be two systems side by side, one public the other private. Under the Public System all Americans, (whether or not insured) will be assured the availability of Primary Care Medicine, free or adjusted to the ability to pay 7/24/365. For those who prefer it HMOs may continue to insure for Primary Care but their major thrust will concentrate on High Tech, Consultative and Surgical practice, covering in-office as well as special procedures performed in hospitals.

At the very least, the immediate benefits of this change would:

Assure  Primary Care coverage for the 40 million who currently have no medical insurance and make Primary Care Medicine available for insured individuals who feel the need for medical care at times their personal physicians are unavailable.  

 Relieve Emergency Rooms of the burden of people congesting these centers for simple ailments normally handled in a doctor’s office, because their doctors are unavailable, or because they are not welcome elsewhere. 

 Give the public a chance to compare the efficiency of public and private systems.

A fringe benefit might be a wider scope of Primary Care than now exists in many places. Primary Care under the HMO system is losing ground as a choice for young doctors because much of it has been relegated to a newly arrived specialty known as “Preventive Medicine” which, except for immunization could probably be practiced over the telephone.  Primary Care doctors do manage diseases that have been diagnosed and prescribed by specialists, an important chore but the days when the “family doctor” set broken bones, delivered babies and operated are over and properly so. But unfortunately the days when the Primary Care would normally manage a swollen knee and draw the fluid if needed, or inject a bursa, remove a cyst, or check a urine through a microscope are also over. Ask your friends whether or not their “primary care” doctor ever removed wax from their ears, drew a pap smear for the lab, checked a drop of urine through a microscope, excised a cyst or did a rectal exam to check for prostatic or rectal cancer. A current oft repeated criticism of primary care physicians is “all he does is refer me and write prescriptions”.    

 Primary Care physicians do not venture far afield because they have been handcuffed and “mind-cuffed” by the threat of litigation, subsequent retribution by the HMO and the fear one day of being grilled by a lawyer: “Doctor when did you become a Specialist in orthopedics (or urology, or dermatology)”.   However as a Federal employee the doctor would practice under the Federal Tort Claims Act (FTCA) that decrees: “A patient who alleges acts of medical malpractice---cannot sue the--- the provider directly, but must file the claim against the United States”,  whereby the Attorney General becomes Counsel for the Defense, a daunting hurdle. 

The building blocks of my proposal are in place, but the must be multiplied many-fold, and made available day and night.  

It would be costly to establish but at a time when dollar bills are being scattered by the trillions the timing seems propitious and politically do-able. NO NEW LEGISLATION would be needed. With each Center employing about 20-30 personnel (increased proportionately if open nights and weekends) and were the number of these CENTERS to be tripled, an additional million jobs would be created. Large sums would be saved through efficient use of resources, integration of care, decongestion of ERs, and reduced number of referrals. Because the Centers are independent entrepreneurs and charge variable fees for service, fear of the “S”: word, (aka Socialization) and the other “S” word (aka Single-payer) are set aside. With Primary Care assured the costs of complementary insurance for families and business enterprise would be sharply reduced because in the main, younger people require little more than Primary Care.    

Thus the Pilot Program of a National Primary Care Medical System is in place and functioning efficiently in 8000 or more of its Medical Centers. Now it is up to the President and his Administration to convert it into a Flourishing Primary Care Health Care Network that serves the entire country.