In 2005, approximately 200,000 Tennesseans were disenrolled from TennCare. Many newly uninsured patients came to my practice because I was one of the few physicians in the area that would see them and the charges at my clinic are much lower than other physicians because I don’t incur the $200,000 per year cost of billing insurance.

Wven though TN had to drop Medicaid enrollees, there was a $100 million tax surplus in 2006 some of which was given to county health departments to expand their primary care capabilities to take care of the uninsured. I was critical of the governor’s plans – and my oped pieces appeared in both the Nashville and Memphis newspapers during that time.

My county received enough subsidies from the state govt to build a $million expansion and hire three primary care providers. Over the next 3 years, even though my clinic has continued to see new patients, my patient volume dropped about 30% (while my fixed costs remained the same). It should be mentioned that no other nearby county in Northeast TN received subsidies to expand their primary care clinics. They not only provide doctors services at no cost to patients but the medicines and the labs as well. It is very hard to compete against free.

While I was looking to add a physician in 2006 I have had to cut the hours my practice is open and work in area ER’s to make up for the lost income, providing many of the same services at 5 to 10 times what I charge in my clinic.

I have been wanting to find out the true cost per patient visit it takes for the health dept to provide their services so as to compare them with mine. I have asked my state representative about how I could get that info. He said, “Good luck – I’ve asked the same question and was told it was impossible for them to give me an answer.” So, we don’t know the true cost of providing medical services at the health dept. But I can tell you to the penny what my revenue and overhead is per patient visit.

So, when the govt disrupts and distorts markets through subsidies, the total cost to society increases…first by making it more attractive for doctors to work in high cost settings and second by disrupting the natural exchange among citizens of a community. One could calculate the increase in social cost if only one could find out how much it costs the health dept to provide the services that I provide. But, apparently this information cannot be gotten. So, it appears that the govt can remain unaccoutnable about its social costs, while a private practice like mine is accountable to keep its costs low or risk going out business or disrupting the medical market so much that the opportunity cost of starting a practice like mine so far exceeds providing these same services in other, high cost settings that not even the more personal benefits such as autonomy, time with patients, working in freedom, can compensate for the economic loss. I would venture to say that the government option is always more expensive since there lacks the natural mechanisms of accountability.

Just an observation.

This EMTALA rule has turned hospitals and medical staff into slaves who follow the federal unfunded mandate or risk a $50,000 fine to each person as well as the hospital for not doing so. Imagine you are a young internal medicine doctor or familty doctor, or ear nose throat doctor on call for emergency admissions (as is required for hospital priviliges) and practically every patient you are required to admit from the emergency that week of call is indigent or illegal – and they can sue you for malpractice but they are clearly not going to pay for your services!

Keep in mind that the hospital is having to overcharge only that subset of patients that do not have an insurance company that has contracted for a specific fee for services. If you are paying the hospital out of your savings, without insurance, you will be charged possibly 3-4 times more in some cases. I really believe that no hospital administrator would accept federal funding to double the nursing staff, Xray and other ancillary staff (that operates the ER) as well as doubling the number of ER doctors. Why? Because this would facilitate caring for larger numbers of ER patients. But this would only attract more and more indigent, illegals, uninsured, and draw even more patients who would go to the public-funded hospitals and lead to an even greater amount of unremunerated care and even redder bottom line. There is currently no incentive to take the burden off the backs of the medical staff since their numbers are the rate limiting factor that keeps the flood of non-payers from increasing.

The other factor in the US, less so in Texas, is the failure to bring about tort reform in order to save costs from unnecessary testing as well as encourage more high risk specialists (eg obstetricians, neurosurgeons, etc.) in areas where these doctors avoid practicing. Obama has completely avoided any promotion of tort reform since his has received contributions for the trial lawyers of America and they will indeed enjoy a windfall in profits over the next 2 decades as the quality of medical students takes a tumble. Yes, more and more superb and brilliant minds that would have become our talented surgeons, innovators, and bright medical whizzes will seek investment banking, wall street, business, etc. rather than go into an interesting and stimulating career in which they are slaves to the government dictating their remuneration and especially being subjected to incrimination every day from tomes of minutiae emanating from government regulatory agencies that spew idiotic requirements every two weeks. And if caught not following to a “t”, will lead to expensive defense legal fees, fines, being removed from Medicare (which will remove you from hospital privileges, etc.) How would you feel if you owned a grocery store and the government told you to sell tomatoes to the elderly for half price (which is your cost) and, by the way, you received bimonthly regulations concerning how you must present them, clean them, etc etc., and then find out you did not do something or other that you failed to catch on one of their little routine letters and would be fined $50,000!? You might just quit offering the half-priced tomatoes altogether and tell the elderly to go elsewhere. This is self-preservation, not greed!

So, “public option” will lead to mandatory governmental regulation over all doctors, hospital or officed based and subsequent oppression by bureaucrats thus leading to early retirement and intimidation of would-be brilliant students seeking the medical field. We have already seen office primary care practitioners quitting (like me) or others who stop admitting patients by relinquishing their hospital privileges and leaving your care to the predominantly (more “easily bridled”) foreign-born medical graduates in the new field of “hospitalists”. Those who are on call and have to admit non-paying patients have become hornery and downright mean people and hate the profession. I don’t see patients better off now since the government and insurance companies have stepped in on behalf of patients “to protect them from greedy doctors”. I really have seen greedier insurance companies deny treatments, refuse to enroll patients as they cherry pick only healthy ones. The government has promised to “take care of old people and the indigent” but in reality have twisted the system to deny fair remuneration to those who provide the health care and to devise a system that would incriminate any honest doctor by overwhelming him/her with inordinate regulatory minutiae impossible to follow – thereby blackmailing him into accepting slave wages.

You young people will bear an even worse brunt since Congress is hell bent on destroying the medical profession out of their contempt for a mythical monster they see as the “greedy doctor”. Every profession has their percentage of entrepreneurs, gold-chained money seekers, etc. and Congress has succeeded in taking away any incentive for a person with superb intellectual talents to want to be a doctor. I personally have seen the quality of medical students and doctors drop in the past 20 years, but I expect it to worsen. Even those with a “calling” will be weathered down by a crass and slavemaster government and insurance company dominance that will eventually neutralize any desire to keep that doctor’s “halo” bright and shiny. I am sure there are classic “liberals” who will be inclined to dedicate their lives to humanity without fair compensation but we need stouter hearts and minds than those commie pinko nutcakes. The bottom line is still going to be a decline in what was once superb patient care. I have written enough as I have stopped thinking and have begun to FEEL too much at this point.

In other words, the payment of taxes (premiums) has no relation to the payment of benefits – they are two separate transactions.
While taxes (premiums) are compulsory, payment of benefits is discretionary.
In fact, “benefits beyond the due and payable amount are not present obligations of the Government and should not be recorded as liabilities.”
See page 31 of http://www.fasab.gov/pdffiles/socialins_exposurefinal.pdf.
Don Levit