I started blogging because I enjoy telling stories. Always have, always will. I think that many people read what I write because they like reading stories.

A recent comment by Max Kennerly, an attorney that frequently comments on this blog, made me sit back and think quite a bit. I don’t always agree with Max or with Matt, the other attorney whose comments drive me nuts sometimes, but I do respect their opinions. Another goal of this blog is to create an atmosphere of debate and debate runs deep on some posts. That’s a good thing.

Max wrote:

I still don’t understand your EMTALA obsession; the Chicago example makes quite clear an ER can cheaply and quickly comply, and still engage in profitable patient dumping. EMTALA isn’t a big deal from the policy perspective, you just find it personally annoying.

Frankly, the ease with which you (and other physicians) conflate issues makes it very hard to take any of you seriously. Do you want to be treated like a private industry or like a public utility? In the same breath you complain that the state is not providing funding and that the state imposes too many limitations on you. Who you think you are, Wall Street?

Normally, we do not give an industry state funding without substantial controls on it, including controls to ensure widespread availability of the industry’s services. But you apparently want the former but not the latter. Well, so do I. I want taxpayer money to go about my private business. Ain’t gonna happen.

I, personally, favor the public utility route, and would be happy to pay the extra taxes to fund it. Where do you fall?

After reading Max’s comment, I read back through my most recent posts on this blog (some imported to this blog – see Archives at right). Then I read back through the earlier posts on my old blog. Max is right. My mindset has definitely changed.

Then I thought about why my focus has changed.

I’m worried about health care in this country. I’m not worried for myself, but I am worried for so many hardworking people  who are denied health care or who have no access to health care. Policies like “never events,” agencies like JCAHO, misguided and medically unsubstantiated sites like “HospitalCompare,” and laws like EMTALA all start out with noble intent (I presume), but they all end up causing ripple effects that degrade the practice of medicine.

So in answer to Max’s comment, my “EMTALA obsession” wasn’t intended to be focused on EMTALA. Rather, my focus is on the ability of every American citizen to access healthcare. I have several Google news feeds that arrive in my e-mail each day. One of them is for the term “emergency room.” I know. I know. I cringe when I type it, but people haven’t caught up with the times. “Emergency department” hardly gets any news … yet. Every day I read posts about how hospitals are closing or losing money because of unfunded medical care. At the heart of unfunded care is EMTALA. So many of my posts reference EMTALA because EMTALA is abused to the point that medical care in this country is doled out arbitrarily. Patients that need urgent care are often neglected or do not seek timely care because they cannot afford it while patients who want “free” pregnancy tests or narcotic prescriptions pillage the system.

I have repeatedly said that a free market approach to medicine is the only way to save the system. Patients must have some “skin in the game.” Unfortunately there will never be a truly free market because, unlike almost any other industry, medicine is a human “need” – not a human “right,” but a human “need.” What other industry has such a closely entrenched human need? Those who can’t pay for a Lexus simply don’t get their Lexus. They can ride a bike or hitchhike. Those who can’t afford a civil lawyer may have their rights trampled, but they still get to go on with their lives. Those who can’t pay for health care – especially emergency health care – will die. Lack of medical care has an immediate and significant effect on morbidity and mortality. I can’t think of any other industries more necessary than medicine – including law. Sorry, Gerry Spence, you’re just flat out wrong.

The intent of all my policy posts is to make people think about the secondary effects of the choices they make, not to force my opinion down anyone’s throat. For example, many who clamor for true “socialized medicine” have this dream that they will get fast, free, and quality care. Such a system will never occur. NEVER. Rationing will be necessary and significant in any socialized system. I try to emphasize that point by illustrating all of the cuts taking place in our current system as we move toward socialism and by showing articles about the lack of access to care in other socialized systems. If we’re going to choose this system, at least we should have an idea of what we’re in for.

You want me to pick public versus private industry? I pick private industry. You pay me, I treat you. No third parties. Screw the government. Every medical provider would have free choice to choose who to treat and who not to treat. No provider would have to treat patients without insurance any more than a grocery store would have to give groceries to someone without money. “Patient dumping” wouldn’t mean anything other than a medical provider making sound business practices. Lawyers couldn’t threaten health care providers with EMTALA violations or all of their other creative iterations of negligence solely because providers choose to make a profit. If patients can’t afford their cardiac catheterization or their expensive medications, they die. Sucks to be them. Is that the system you want? You wouldn’t hear very many providers complaining, but at the same time, thousands of people would die because they had no money for medical care. I’m all for free market, but we can’t let purely “free market” medicine happen to patients.
So let’s impose strict “state controls” on medicine. Everyone is a comrade and gets their government-sponsored Yugo and bowl of gruel. We can already see what happens with a purely government controlled model. Look up North or across the pond. Sure, care for healthy patients is easily accessible. But become one of those “high utilizers” and it’s a different story. Long waits. Less care. People die waiting for surgery. Expensive treatments for sick patients are denied because some government accountant says the treatments are “not medically necessary.” Impose your controls. Go ahead. You won’t be able to pay enough in extra taxes to fund a system that provides good and timely care to every denizen in this country.

What I foresee happening is a system similar to the legal system in this country. For emergency care and surgical care/hospitalizations, there is a “public defender” type system. If you can’t afford to pay for a top notch “defense” physician, then the “courts” appoint a “public defender” physician for you. You get average care if you don’t have the cash, but you have the option to pay for Mark Geragos if you can afford him. Top surgeons or emergency physicians could demand and receive a premium. Just like the Mayo Clinic or M.D. Anderson, now. People pay extra for extraordinary care. Market forces at work. The “public defender” system is already emerging in emergency medicine with the proliferation of freestanding emergency departments that can cherry pick paying patients. Those without money go to the “public defender” emergency departments at public hospitals that still fall under … EMTALA laws. See, I mentioned it again.

Routine medical care will drift toward the “civil law” practice model. Pay to play. No money, no care. Maybe you can go to public clinics – the equivalent of law schools or charitable organizations – to get primary care if you demonstrate a need. Once the governments decide to cut funding to public clinics, patients will either have to pay up or go sit in the untenable lines in the emergency departments for their care.

I will be able to care for myself and my family regardless of the system that is chosen in this country. I have the contacts, the resources, and the knowledge to do so. One of the benefits of having a six figure student loan debt, I guess.
I truly fear for the health and livelihoods of those who aren’t as fortunate as I am.

That’s where my posts are coming from.

On the flip side, I really do have to get out of my writing rut. Thanks for setting that straight, Max.