The Governor's Health Plans

I am a member of the Los Angeles County Medical Association Board of Directors and its Health Information Taskforce subcommittee. This subcommittee is charged to respond to Governor Schwarzenegger's recent health reform ideas. We have done so first by outlining ten principles we believe are crucial to health care reform.

These principles (side bar) and a preamble were adopted unanimously by the LACMA Board and submitted to the governor. Meetings to discuss them with Lt. Governor Garamundi and with Mr. Herb Schultz the Governor's health assistant are scheduled.

At the risk of sounding out of step with the governor and some others in Sacramento, we do not have a crisis of access to health care. All Americans can be seen the same day for any illness regardless of their insurance status by federal law (EMTALA, an unfunded federal mandate enacted in 1986 requiring all comers be seen in any ER any time).

This law is obeyed. Such ER access actually existed before its passage 99.9% of the time by professional tradition and ethics. Ironically, the EMTALA mandate puts such ER access at risk by indirectly encouraging hospitals to close their ERs to avoid EMTALA's costly consequences. However, for now the access does exist.

There is a true crisis of access in Calcutta, India, where trucks scoop bodies off the street each morning, dead people who were not welcome in area hospitals. There is no EMTALA in India and no tradition to serve all in urgent need as there is here.

There is a crisis of access in Canada, where you can wait three years for critical tests, such as a sleep study, and die of obstructive sleep apnea in the night while waiting for your critical diagnostic test. Obviously, single payer access to a waiting list is not access to care and the Canadian Supreme Court has recently so ruled in reaction to numerous such cases.

We also do not have a crisis of the uninsured. There are only 17 million persistently uninsured and they have access to care and insurance. Moreover, many are not US citizens but illegal aliens. The other 28 million uninsured also have access and are only temporarily uninsured for a few months between jobs. They then get insurance again through their next employer. In California an "assigned risk" state program called "MRMIB" allows any uninsurable person to buy affordable health insurance just by submitting one insurance company's application rejection letter. Most states have such assigned risk programs.

In fact the uninsured fare better in terms of outcomes than those insured by Medicaid (MediCal in California). This is pointed out and referenced in David Gratzer's excellent new book on health care reform "The Cure", recommended reading for anyone serious about this subject. Medicaid is an example of how poorly single payer government insurance works. This is what Americans can expect under proposals for universal single payer government sponsored insurance in the unlikely event it is adopted.

Meanwhile, the cash medical market is becoming more transparent and usable day by day. Five to eight million Americans are now in Health Savings Accounts and their numbers are growing exponentially. Seventy percent discounts are available to all comers for cash at many hospitals. Medical tourism overseas offers inexpensive high quality care to patients who use this growing alternative. Medial tourism is also forcing US hospitals to cut cash prices dramatically. Specialty hospitals offer better care at lower prices for focused problems.

No one is denied free care if they look for it. Public health clinics give free vaccinations to all. Free clinics are better funded and organized than ever before. An uninsured patient in a hospital can get on MediCal almost instantly.

What we have is not a crisis of health care access or insurance but an artificial crisis made possible by the health care entitlement mentality of Americans. This entitlement mentality exists because of the unintended consequences of government interference with the health care and health insurance market over the past 70 years.

Moreover, that government created crisis is useful to politicians. What we have is not a health care crisis, but an opportunity for politicians who constantly need issues to keep dollars rolling into their campaigns. Politicians seek ways to leverage voters, unions and businesses to serve their ambitions.

Insiders know that the governor sees attaching his name to health care reform as the route to the US Senate in 2010. Assembly Speaker Nunez sees attaching his name to health care reform as his route to Mayor of Los Angeles when he is termed out in 2008. No doubt many politicians and the governor are sincerely concerned about health care, but the current health care debate is largely a political tool understandable only when viewed through that lens.

There is plenty of money in health care right now. Much money is wasted by the first dollar health insurance industry violating every principle of real insurance. Insurance should pay only for unexpected, high cost events not colds and office visits. Much money is wasted by insulating Americans from the true cost of basic health care with the resultant entitlement mentality so engendered.

Yes, we need to take money away from United Health Presidents who retire with a billion in the bank and Blue Cross/Wellpoint Presidents who retire with 1/3 of a billion in the bank as both did recently. However, we must not give that money to the government. If we do we will only get care as in Canada with access to a long waiting list.

We need to give the money back to the citizens who earned it in the first place and who can then buy their own basic care in a free transparent market. They will themselves limit their own consumption to what they really value. Then there will be plenty of money in the system to cover the real needs for market and patients sensitive care.

There is no other solution short of turning gradually into India.