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Here's a health-care fix that's small but powerful

  • Comprehensive health-care reform is dead. But health-care problems live on.
  • Lawmakers need to come together. They should start with Medicaid.
  • Medicaid was conceived to provide care for the poor and disabled.
  • Obamacare expanded the number of people covered under Medicaid and blew a big hole in state budgets.
  • Expanding charity care by doctors would be a small but powerful bipartisan fix.
A nurse listens to a client's chest at the Spanish Catholic Center agency of the Diocese of Washington Catholic Charities.
Jonathan Ernst | Reuters
A nurse listens to a client's chest at the Spanish Catholic Center agency of the Diocese of Washington Catholic Charities.

Comprehensive health-care reform is dead for now. But the problems facing the nation's beleaguered health system live on.

Lawmakers must now come together to make bipartisan reforms on the margin to shore it up. They should start by addressing Medicaid, which isn't working for doctors, patients, or taxpayers. Expanding charity care can help.

Medicaid was conceived to provide care for the poor and the disabled, but was expanded under the Affordable Care Act to cover able-bodied men and women earning above the poverty line. As a result, it now covers nearly one-quarter of all Americans.

This enrollment surge has blown a hole in state budgets and will only grow as the federal government shifts costs for new enrollees to the states. According to the Congressional Budget Office, which has consistently underestimated future Medicaid enrollment, Medicaid spending between 2014 and 2022 is projected be over three-quarters of the program's total historical spending before 2014. This will further crowd out other state priorities such as schools, roads, and middle-class tax cuts.

"Small yet beneficial reforms are now the best hope to improve American health care."

The program also isn't working for doctors. The reimbursement rate is roughly half that of private insurance, according to research by the Kaiser Family Foundation. Participation requires reams of paperwork, approvals, and delays in reimbursements. Patients, as a result, increasingly cannot find a doctor to treat them. Over half of doctors no longer accept new Medicaid patients, according to the Department of Health and Human Services, and stories of patients trying dozens of times in vain to get an appointment are not uncommon.

Expanding charity care can relieve some of the Medicaid burden. Perhaps even more importantly, such an uncontroversial reform could achieve the bipartisan support necessary to become law.

Charity health care, where doctors volunteer a certain number of hours a week and donations cover variable costs, has a long history in the United States. There are currently over 1,200 charitable clinics nationwide, largely operating outside and parallel to the Medicaid system.

One major advantage of charity care is that doctors can have their medical insurance costs covered by the federal government under the Federal Tort Claims Act when working in a charity clinic that meets federal government requirements. This allows them to provide good care, but not excessive or defensive medicine, worried that their good deed may go punished.

Charity care could be expanded further if state governments, which have the most to gain from its implementation, cover the private practice liability insurance costs of any physician who volunteers a certain number of hours per week in a free clinic.

Such a trade would be a bargain for both doctors and state governments. The average primary doctors would save roughly $12,000 in annual malpractice insurance premium costs. Specialists would save even more. In return, by keeping Medicaid, uninsured, and undocumented patients out of expensive and overburdened emergency rooms, the state would save hundreds of thousands of dollars per doctor. As an added bonus, defensible and costly malpractice lawsuits would likely be reduced because of the bigger burden associated with suing the government instead of the individual physician.

Dr. Alieta Eck, who runs the Zarephath Health Center, a charity clinic in Somerset, New Jersey, shows how this model can work in practice. By relying on donated physician time and cutting out the burdensome Medicaid bureaucracy, the cost to provide care comes to $15 per patient visit (covered by donations). This is compared to the roughly $1,000 it would ultimately cost the taxpayer if the patient ended up at the ER.

She's spearheaded a New Jersey bill, S239, that calls on the state to provide liability coverage for the private practices of physicians who donate at least four hours per week in a charity clinic. Similar proposals are alive in several states across the country.

While trial lawyers may object, opposing charity care expansion is a dim prospect for even the most hardened partisan legislator. Such small yet beneficial reforms are now the best hope to improve American health care.

Commentary by Joel L. Strom a Beverly Hills dentist and a fellow at the Unruh Institute of Politics at the University of Southern California.

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