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Republicans hate free clinics. They get angry when you discuss them. The idea of someone getting something of value and not paying for it clearly just makes them crazy. We may have something here. We've heard that there's no free lunch, but what about food banks, soup kitchens and even the Hare Krishna handout? What's next? Free love?


You must enter an Intro for your Diary Entry between 300 and 1150 characters long (that's approximately 50-175 words without any html or formatting markup).

This is the second installment in my series of good, but seemingly ignored schemes to institute free, universal medical care in the USA. I'm not the only one who thinks eliminating private health insurance is at the root of solving our health care crisis. Read this: Eliminate health insurance and everyone wins.

Today's piece is an expansion of the following idea from Monday's poll.

The government opens the doors of all United States Public Health Service facilities to the general public, converting them into free clinics.

Simply put, the idea is that universal health care can be instituted immediately by doing it first, then arranging the financing later. It can be done and it ought to be done, just as they did in Great Britain in 1948. The problem of what to do with private health care insurers, the main stumbling block for Congress, is leapfrogged. We just cut them out of the picture and ignore them as they wither on the vine.

This is not really much of an innovation. Free USPHS clinics is what we have on the Native American reservations. Let us not forget that Indians are Americans who pay taxes as everyone else does, but with the exception that they have fully-funded, free medicine as part of their treaty rights as sovereign peoples who predate the U.S. government. They got that deal as part of a bargain they made to stop fighting the hordes of Europeans displacing them from their land. It may have been a bad deal for them overall, but it was a binding agreement nonetheless. Over the years, they realized that free medical care has great value and they have shrewdly held onto it. They may be even smarter about this than the British who have had the good sense to retain the system that fell into their laps in 1948. Native Americans have done even better. They are a privileged class, guaranteed universal medical care that they and their fellow citizens pay for, but no one else gets. Opening the clinics to the public at large would move all citizens into this same privileged class. The idea is not to take anything at all away from Native Americans, but to treat everyone else as well.

Sounds easy, doesn't it? It is. What bugs me the most about this obvious solution, mobilizing the standing army of USPHS doctors to meet the needs of the general populace, is how easily it could be done. The President could take the first step with a stroke of the pen. He could order them to do it because the USPHS is a uniformed service under his direct command. (The Commander in Chief is the CINC of the USPHS, too, just as he commands the armed forces.) Yes. It's just that easy.

The order would be the thin edge of the wedge that might barely be noticed. There are very few of these clinics outside reservations. Their impact would initially be small in urban areas because the tiny facilities would be overrun with the working poor who have no health insurance and can't afford care when they need it. The quirky part of this scheme is that extensive free, public clinic support already exists in urban areas. These "hippie clinics" struggle and get by mainly on the altruistic dedication of the staff who forgo professional remuneration to pursue their calling. They get grants and charity to supplement the meager user fees they can glean, but mostly they are hand-to-mouth operations.

Existing free clinics point out the hypocrisy of a government that is Constitutionally obligated to "provide for the general welfare", but ignores the health of its people. Once poor people have a choice, the old free clinic or the now accessible USPHS clinic, it begs the question, "What's the difference?" Here's where a bold-thinking U.S. President could really finesse the issue. He could obliterate the distinction by offering a direct commission in the USPHS to any free clinic doctor or registered nurse who wanted one. In addition to a snappy new uniform with gold braid, the clinic where this medical professional worked would then become a de facto USPHS clinic.

The commissions and uniforms may not cost much, but salaries would. The President could bypass Congressional funding initially by enrolling newly-commissioned USPHS officers under some euphemistic rubric such as "detached status", where they would not be paid. They could choose to practice medicine or not, but would only be paid if they "activated" and went to work for the USPHS in one of its clinics. The incentive to accept the commission would be that they accrue service toward retirement by practicing medicine full time.

Now it gets cute. The thin edge of the wedge is in; the nation is heavily dotted with free clinics staffed by USPHS officer doctors and nurses. The right-wingers would be livid over the insidious government takeover of... Oh, wait. They don't care about free clinics and other hippie medicine stuff. That's for poor people, and even low-wage, low-information, poorly educated ditto-heads think of themselves as "middle class". They might even be relieved that the government has backed off on encroaching on their "good", expensive, insurance-based medicine. There is no talk of single payer systems. Insurance companies are free to continue gouging and denying services to sick people.

But! The paradigm has shifted. New rules are now in play in the free market. It's the Microsoft model of giving away the Internet Explorer browser that killed Netscape Navigator: Why pay for what you can get for free? Suddenly, the uninsured poor have options. They can go to the local USPHS-staffed free clinic or possibly even a real USPHS clinic and get treated for free. The lines are not any longer than at the ER, and at the real free clinic they don't bug you to pay more than you voluntarily chuck into the coffee can at the front desk. (At the USPHS clinic, there's no coffee can.) This notion catches on and soon all uninsured people, except the wealthy who can still easily afford expensive fee-for-service doctoring, routinely go to free clinics and get treated. We're talking about 50 million people here, at least to start, but the numbers grow rapidly as unemployed workers forgo COBRA plans despite misgivings about "taking charity". The hardest change in mind set may be letting go of the idea that health care should cost a lot of money.

As soon as a sizable segment of the population drops out of the official scheme of rationing health care by confiscatory insurance, that system begins to crumble more rapidly as the sentiments of the populace reach a tipping point. The first to drop their insurance will be those with individual policies who are being gouged. Everyone has a limit to what they are willing to be charged for "good" health insurance, the kind that pays for all medical services. If you can't afford that, and few people can, you get as much coverage as you can afford. The higher the deductibles and co-payments, and the lower the caps and limits, the less useful that coverage is. People ratchet down in coverage to the point where the insurance purchased has far less value than keeping the cash paid out in premiums. They cling to the notion that the insurance will pay off in times of great necessity, even when objective analysis proves that it will not. Eventually, though, they just stop buying insurance.

They way it is now, poor, low wage earners often feel that they can still afford some kind of crappy catastrophic insurance. But, what if they had an alternative for that catastrophic case, such as the local free clinic? Poof! The whole junk health insurance sector is wiped out! Wouldn't you like to see that happen, not by governmental fiat, but by free market pressure?

The next type of defector from the insurance scam is the worker changing jobs. With free medical care available during times of unemployment, the worker may have already used a free clinic before starting a new job. If the employee group plan is not very good, a new employee will boldly decline coverage and "go naked". With a well-functioning free clinic system, that would no longer be an irresponsible, irrational act, as it is now generally considered, but a shrewd market decision. Once choosing not to get ripped off is a viable option, a lot more people will take it. This is the death knell of for-profit health insurance.

A very small segment of the population, but an important one, is the financially secure intelligentsia. These people are the educated elite who know what's really happening because they wrote their doctoral dissertation on the topic, or at least know someone who did. This segment also includes politically and socially aware people of conscience who take moral stands on issues and back it up with their time and their money. The morally committed may or may not be educated professionals, but they feel strongly enough about issues to do something about them, sometimes at great personal sacrifice. Once these folks of raised consciousness pick up on what's happening, they will cancel their policies, quit their HMO's and flock to the free clinics. There will wait patiently in line with the homeless and working poor, then drop checks for $100 or so into the coffee can. They will talk up what they are doing, too. There will be news stories about people of means "opting for public medicine" as a matter of conscience.

The ball will be rolling. Employers will give up trying to woo employees with subsidized health insurance and just pay them more, funneling their workers into the public system. The more people who cross over the line to free medicine, the greater the incentive for others to do so. The irrational fear of being uninsured inculcated by insurance companies will dissipate. Eventually, the consensus will be reached that publicly-financed medicine is like publicly-financed firefighting: You have to have it and it doesn't make sense to do it any other way.

One of the great misconceptions in modern society is that political leaders lead. Our electoral system guarantees that the most successful politician is the one who best panders to populist sentiments while cutting secret deals with special interests for campaign funding. In both ways, they are followers, not leaders. The promise the people what they clamor for and think they want, while cravenly selling out to the highest bidder. There may be little connection between public promises and the private deals made.

Given that, what do you think will happen when, say 25% of the population, relies solely on free clinics for all medical care? Bear in mind that the proportion is about 15% (45 million or so) right now, and grows every day. If you have no insurance and no money where else can you go? I'm certain that public pressure for government support of free clinics will swell and grow as a true grass roots movement. People will bug their members of Congress to fund the free clinic they use. We'll get appropriation dribbling in for medical supplies, bargain-priced generic drugs and sweetheart deals on clinic facilities from local governments using federal funds whenever they can.

Eventually, the free clinics will be mainly government supported. They will quietly remove the coffee cans. A bill will be pushed through to activate practicing USPHS doctors and start paying them their full salaries. All programs are expanded as Congressional appropriations permit. Within a shorter time than anyone thought, we will have comprehensive, universal medical care available for all citizens.

It could happen. Of all the insurance-killing schemes I've considered, expanding free clinics seems to have the best chance of succeeding. This is not wishful thinking. There are people right now, such as the Mad As Hell Doctors, who are putting the scheme I've outlined into practice already, but without any support from the USPHS. Everywhere they go, people say, "God bless you," with tears in their eyes as they get the first medical attention they have had in years. The reaction is all good. Even Fox News can't bring themselves to badmouth volunteers treating needy people who line up at health fairs for treatment. Even if you're skeptical, you've got to admit that the process has already begun. When will you get on board with this? This could be a winner.

Tomorrow, we'll get into the public option competition scheme.

Extended (Optional)

Originally posted to DisgruntledCurmudgeon on Thu Dec 31, 2009 at 04:15 PM PST.

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