Abstract
There are a great many problems in the United States associated with access to healthcare, not the least of which is the fact that the terms healthcare and health insurance have become nearly synonymous to the public. Fundamental conceptual flaws in our paradigm for healthcare payment are worthy of consideration and will be the subject of future editorials. However, altruism and the current legislative debates require that we first consider our most pressing problem: the best way to care immediately for Americans without health insurance.
Most physicians agree that a country as wealthy as the United States should have some system to protect our citizens who have essential health needs that they cannot afford. However, solving that problem has led to extremely contentious debates, legislative proposals that threaten to bankrupt the country, and discussion of coverage “requirements” that are not consistent with the principles of democracy and capitalism (and which might even be unconstitutional). The proposals, debates and posturing suggest that they are driven by political agendas rather than by a pure commitment to caring promptly for our uninsured population, since there seems to be an obvious solution that apparently has not been entertained seriously.
First, let us consider the real magnitude of the problem. The best available numbers are based on the most recent U.S. census. According to the census report, in 2007 there were 45.7 million people in the United States without health insurance. 1 However, this number bears closer scrutiny. Wenger summarized important subsets of those census data:
14 million of those uninsured are below the poverty threshold and are eligible for Medicaid, but they have failed to apply for Medicaid.
11 million have declined health insurance offered to them by their employers because they elected not to spend the portion of their pay required to cover the employee contribution.
18 million of the uninsured have a household income of more than $50,000 per year; and, interestingly, 9 million of those have a household income of greater than $75,000 per year.
9.7 million of the uninsured are illegal immigrants. 2
It has been pointed out that 70% of the uninsured people in the United States actually have access to health insurance but have elected not to obtain coverage. 3 Let us take a conservative look at the real number of uninsured who reasonably may be considered for care at taxpayers’ expense through a new approach. Certainly, we can subtract the 14 million Medicaid-eligible Americans from the 45.7 million. The system is already prepared to cover them, and all they have to do is apply.
I would also contend that we should not hesitate to subtract the 11 million people who have declined health insurance from their employers. The United States is a democracy. If people elect to gamble by not insuring their homes, their cars, or their health when they have the ability to do so, that is their right. If they choose to run the risks of being uninsured in order to be able to spend their money on something else, they are exercising freedom of choice but must also accept responsibility for the consequences of that choice. If that decision leads to the loss of a home or a lien against future earnings in a democratic society, then so be it. There is no reason why taxpayers should be obligated to bail out what essentially amounts to a lost gamble.
Even eliminating only those groups, the number of uninsured drops to about 20.7 million. Arguments may be made about whether the 9.7 million illegal immigrants or 9 million with household incomes exceeding $75,000 a year should also be subtracted (there is some overlap in some of the groups defined above). However, even without addressing these groups, the magnitude of the problem is clearly not quite as overwhelming as the number bandied about by politicians.
If the President were to decide tomorrow that his real and only immediate concern is to provide basic and emergency healthcare access to the legitimate uninsured who need it right now, is there a way to do that cost-effectively and expeditiously? I would argue that we already have an excellent federal healthcare system in place that could be used to ameliorate the current crisis without disrupting the healthcare system, forcing through incompletely considered legislation, or instituting additional nondemocratic (socialist) “reforms.” The Veterans Administration (VA) is an excellent, generally well-run, widely distributed federal healthcare system that, with augmentation, could care for the uninsured population and would cost far less than any of the proposals currently under consideration.
Currently, the VA has the nation's largest integrated healthcare system, with 153 comprehensive medical centers and approximately 768 outpatient clinics distributed throughout the United States, where care is provided to more than 5.6 million veterans annually. 4 The VA healthcare system is organized into 21 regions called Veterans Integrated Service Networks (VISN). Each is responsible for coordination and oversight of all administrative and clinical activities within its region.
In 2009, the VA had approximately 270,000 full-time equivalent employees and more than $100 billion in obligations. 4 In providing healthcare to veterans and their dependents, with 5.6 million unique patients in 2009, 99% of primary care appointments were completed within 30 days of the requested appointment date, and scores on Quality of Health Care performance evaluations are high and improving. 4 The VA also has the nation's largest and most sophisticated telehealth program, which already provides care for 230,000 patients in more than 144 VA medical centers and 450 community-based outpatient centers. 4
To put utilization into perspective, the estimated population of veterans in the United States (not including dependents who also may be entitled to VA Hospital benefits) is about 23,400,000. 4 With the VA's proven track record of efficiency and excellence, it seems as if it would make much more sense to expand VA services and provide a prompt, efficient solution to the problem, rather than trying to reinvent healthcare financing in the United States. In addition, even if the VA Hospital budget were doubled or tripled, the expenditure would be far less than the approximately trillion-dollar budget being discussed in Washington.
I believe that if the federal government gave the VA Hospital systems the financial resources required and called upon the VA to rise to the current need, that the essential health needs of the legitimate uninsured could be handled easily, almost immediately, and without any adverse effect on the care provided to veterans. In fact, the influx of resources to enhance the VA system would probably benefit the veterans.
Moreover, if additional physician resources were needed and our federal government were capable of thinking outside the box, recruiting volunteer physicians would not be difficult, either. If the government provided physicians with malpractice coverage for their activities in the VA system (equivalent to the malpractice coverage provided to employed VA physicians), and if the government offered physicians a tax credit for their activities at VA hospitals equal to the amount that they customarily bill for those activities in their normal settings, it is likely that a great many physicians would volunteer their time for a day or two a month, if needed. Their presence would also enhance treatment available to our veterans, in addition to providing coverage for the uninsured. Customary billing amounts are easily verifiable through the previous year's submissions to health insurance carriers. Admittedly, health insurance carriers don't use the billing numbers for much other than calculating the “adjustment” column, but they do have the numbers that could be used for verification to avoid abuse of the system.
This proposal could be implemented quickly, and the uninsured who need healthcare would have a place to go long before our legislators finish debating and implementing the sweeping health financing reforms currently under consideration. To be sure, our system of financing healthcare deserves reform, but taking care of our uninsured should mean more than using them as leverage to revamp our entire healthcare system. If the powers-that-be really care about the health of uninsured Americans, they should open the doors of our federal VA healthcare system to them now, and not hold them hostage to philosophical debate and political wrangling.