If President Obama's health care summit revealed anything in the long hours of partisan whining, it was a fundamental difference in the crisis that each side believes is on the table for Congress to solve. Democrats spoke to a national humanitarian crisis caused by an industry run amok, while Republicans talked of a series of consumer obstacles caused by government meddling in the market place. Who is correct?
To believe the Republicans, one would be forced to accept the central claim they make over and over and over again: anyone at anytime can go to a doctor and be treated irrespective of insurance coverage or financial circumstances.
Is this claim true? Are the uninsured denied care upon going to a doctor?
The answer is: yes--the uninsured are denied care by doctors all the time. How this denial of care happens, however, is something that nobody in Congress or the media has bothered to discuss on the public stage, despite the fact that it is one of the most common and banal evils of our democracy.
To see how patients are denied care by doctors, we must begin by exorcising from our heads the Norman Rockwell painting many of us carry around in our heads--the painting of a boy sitting in the office of a country doctor. For about the past 40 years, "going to the doctor" in America has not had much in common with the nostalgic image of a ruddy-cheeked old man putting his stethoscope on the chest of a nervous teenage boy. That kind of simple and direct interaction between doctor and patient did happen in the past--I vaguely remember it when I was a boy in the early 70s. But it has been a long, long time since things were that simple.
Nowadays, to get into the room with a doctor, we must first make it past the system each practice sets up to weed out the paying customers from those who cannot pay. This often humiliating experience begins with a phone call to the front desk of the doctor's office.
The person who works behind that front desk is in charge of two tasks: (1) ascertaining how the patient is going to pay for the appointment and (2) fitting the patient into the doctor's schedule of appointments--in that order. Barring some personal connection, nobody in America can get a doctor's appointment without getting past the hurdle of payment maintained by the receptionist in charge of maintaining it.
To determine if we can pay for an appointment, the receptionist asks first for insurance plan information. Even if we have insurance, that may not be enough to see the doctor because at this point we may find out that this doctor's office only accepts patients with certain insurance plans. If our plan is accepted, we can move forward, if not, we move on to the next hurdle.
If we are uninsured or our insurance plan is not accepted by this clinic, the receptionist then asks for a valid credit card to cover the cost of the appointment. If we have a valid credit card, we give it to the receptionist and we can move forward. If not, we move on to the next hurdle.
In the absence of a valid credit card, some medical practices will allow us to pay for the appointment in advance using cash. If we can pay, we must go to the office and do so, whereupon we can get an appointment. Many doctor's offices, however, do not allow cash payment because most appointments involve an element of the unknown in terms of final cost. Because of this, "payment in cash" is often allowed only if a patient can guarantee the payment with a credit card number: a deal breaker for many people. Therefore, if we do not have enough money to pay cash in advance and a credit card to back it up, we move on to the next hurdle.
At this point, the receptionist will likely suggest another practice or an emergency room visit.
We have not been denied care by a doctor, in other words, but we have not really made it anywhere near the doctor, yet, either. Instead, we must now head down to the local hospital emergency room and get treated there. Since we cannot pay cash at the emergency room anymore than we could pay at the doctor's office, we will be treated by virtue of laws put in place to recover from state and federal government some of the costs of an unpaid emergency room visit. We will go home treated, but we will not have established any kind of relationship to a doctor. Most likely, we will have been treated by an overworked and under-appreciated medical resident 72 hours into a 48-hour shift.
In some cases, a medical practice who determines a patient is unable to pay will allow a patient to talk to the doctor briefly, either in the doctor's office, in the waiting room, or briefly over the phone. An uninsured and non-paying patient making it into the examination room, however, is possible, although unlikely.
This is not a comment on the individual character of doctors in America, today. Most doctors are selfless and service-oriented: good people with a desire to use their skills to improve people's lives no matter what the cost.
But doctors have a larger concern that most often mitigates their ability to exercise this direct kind of care for any patient who comes their way regardless of financial circumstances. Doctors, today, erect a barrier between themselves and their patients because their ability to treat their covered and paying patients depends on their ability to keep the doors of their medical business open. And so, in order to protect their practice, doctors must look for ways to minimize, if not eliminate altogether, the financial losses to their businesses incurred by treating patients with no means to pay.
Good people, with good hearts, often build business in which they surround themselves with heartless bureaucrats tasked with guarding the gate and protecting the bottom line. And that is often the case with doctors.
The receptionist who is paid to keep uninsured and non-paying patients from entering the doctor's examination room is one of those barriers. Patients, however, also develop internal barriers--psychological hurdles--that keep them away from the doctor.
Americans who lose their health insurance coverage often do not even bother to try to make appointments at the doctor's office out of concern that to do so will risk financial ruin or humiliation.
Since it is not possible to put a limit on how much a doctor's office can charge to a credit card, patients are often worried that giving a doctor a credit card could result in tens of thousands of dollars in charges, unexpectedly. Rather than thinking of doctors as people who can and want to help them--the way most doctors see themselves--tens of millions of Americans think of doctors as financial predators to be avoided at all costs.
Likewise, the pain of having to admit one's own indigent status in the course of making an appointment is often too much for proud Americans to bear. And so they stay away from the doctor.
Is it true, then, as Republicans claim, that nobody has ever been denied care upon going to a doctor? Is this humanitarian crisis in America really just a political fiction as the Republicans would have us believe? Experience and logic lead us to conclude otherwise.
American is packed to the gills with the most skilled and selfless doctors in the world--and millions of Americans, each and every day, despite trying, never make it to the examination room to see them.
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