The Uninsured Problem Needs Tough Minds, Soft Hearts

Published May 2, 2005

“Cover the Uninsured Week” is an eight-day media campaign spearheaded by the Robert Wood Johnson Foundation, a tax-exempt organization with $80 million in active grants dedicated to “ensuring that everyone in America has affordable and reliable health care coverage by 2010.”

On the surface, it would seem unthinkable–even mean-spirited–to contest such a noble goal. Yet problems as difficult as 45 million uninsured require more than grand pronouncements and glib panaceas. They require tough minds and soft hearts.

The tough reality is that health insurance coverage does not equal health care. Yet it is health care–timely, competent, compassionate, and cost-effective–that Americans want.

Universal coverage in Canada forces women with breast cancer to wait 14 weeks on average from first bringing their suspicious lump to a physician’s attention until it is removed. The average Canadian waits more than five weeks for a CT scan and three months for an MRI. In Britain universal coverage has caused a queue of more than one million people awaiting elective surgery.

Tennessee’s decade-long experiment with expanding Medicaid managed care to middle-income families demonstrates the futility of relying on the state to expand coverage. TennCare is about to begin the process of disenrolling more than 200,000 patients. The state simply could not afford to cover 23 percent of its population and still pay for other items in the state budget. And yet, the groups behind “Cover the Uninsured Week” support public programs that resemble TennCare.

I am a Tennessee primary care physician who has roughly 3,500 uninsured patients in my practice. In early March, I attended the first public forum of our governor’s Task Force on the Healthcare Safety Net. Having provided something of a safety net of my own for the past four years, I thought some of what I had learned might be useful to them.

I told them the major reason my clinic is more affordable than other primary care practices is that we don’t take insurance and thus do not incur the cost of filing lots of small medical claims. The clinic requires three fewer employees and costs two-thirds less (or about $200,000) to operate than similar clinics that take insurance. Our fees are little more than the $32 that Governor Bredesen’s consulting group, McKinsey & Co., recommended able-bodied TennCare recipients contribute as a co-pay for office visits.

Our clinic has demonstrated, without using taxpayer money, the potential affordability and decreased costs of direct payment for routine medical care. One wonders if Americans even need insurance for such services.

The tough-minded reality is that if we eliminated the tax exemption for small medical claims and kept it only for major medical expenses, much of the country’s health care financing problem would be solved.

I am not surprised that thus far no one from the governor’s task force has contacted me. People who clamor most vociferously about covering the uninsured are usually the least likely to be found actually caring for them. Their compassionate slogans ring hollow when their personal inaction reveals hardness of heart.

A doctor was once quoted in Time magazine as saying, “Our income is completely controlled by the government but we have no control on our expenses.” It doesn’t have to be that way. Primary care physicians are coming to realize they can escape bureaucratic hassles and costs and still make a decent living by not accepting insurance.

Any campaign–media or political–that calls attention to the plight of the uninsured must also call for the removal of tax and regulatory barriers that impede direct-pay health care. Anything else betrays a soft mind and a hard heart.

Robert S. Berry, M.D., is a primary care physician in private practice in Greeneville, Tennessee.