This is a Cross Publication. It is a practicing physicians view on an approach to how physicians may choose to deal with the 26 million that will not be insured...
The New Requirements of the Old Ethics:A perspective by Marc Tunzi MD.[*1.]
Reprinted From a: Hastings Center Report. 2013;43(2) [*2.] as published in Medscape.
Note: Medscape articles are available on line to its members only.
When I [Dr.Tunzi] was a kid, I used to play the "Where am I?" game. Maybe you did, too. You know: I am in my house; in Salinas, California; in the United States of America; in the world; in the solar system; in the universe. These days, I play a "Who am I?" game: I am a husband, father, and friend; an American; a Catholic and a Democrat—though I often disagree with the official positions of both affiliations; a family physician for twenty-five years and a family medicine residency faculty member for twenty years; a newly minted, Master's-trained clinical ethicist; I staff a volunteer homeless clinic once a week.
Integrating these identities is a challenge. My expertise enables me to see connections among issues that others sometimes do not see. In that context, I believe that U.S. health reform will raise many familiar ethical issues over the next several years—old issues in new forms. One of these is the fate of individuals who will still be uninsured after implementation of the Patient Protection and Affordable Care Act.
According to the Congressional Budget Office, there are 56 million uninsured people in the United States. About 30 million will be eligible for coverage via PPACA—roughly half via an expanded Medicaid program and half via the health insurance exchanges; 26 million will not be covered.
And then what?
There are not enough primary care physicians to provide care for those who will have health insurance. Private medical practices will absorb many of the "exchange half" of the newly insured, but they cannot care for all of them. Public medical administrators will cry, "No money, no mission," promising to expand access quickly but focusing first on the "Medicaid half" of the newly insured in order to compensate for lost block grant revenue that will be redirected to supporting PPACA. Those who still lack coverage will likely find access unavailable.
The future uninsured will include both undocumented residents and U.S. citizens who work without employer-based insurance and would rather risk a fine ($695 per person) than purchase coverage via health insurance exchanges, regardless of federal tax credits. An informal poll of my adult children's friends confirms this. One explained, "I finally got a job—no benefits—and can barely support myself. Pay for health insurance? In a couple years."
This old "new" issue has an old "new" solution. The American Medical Association was founded in 1847 to serve and protect both patients and competent physicians. The AMA is seen as the first organized professional group, and physicians as the first professionals: highly trained individuals with a "social contract" to provide good service to their communities in exchange for the privilege of establishing their own license and peer review standards and maintaining status and income. The AMA Code of Medical Ethics directs physicians to promote "access to medical care for all people" and to "share in providing care to the indigent."
What does this social contract mean? What are we to say to our patients and communities? How are we to act? An informal poll of my colleagues suggests that we do not agree on these behaviors. One told me, "I have worked very hard to get to where I am today, and I work very hard taking care of my patients. What do you want from me?" But I think physicians' contract with society is real: we have real social benefits, and real obligations. We work hard, but we have not gotten to where we are by ourselves, and as a group, we have weathered the current economic crisis incredibly well.
I propose that a minimum standard of public service activities be defined and required by all U.S. medical specialties in order to maintain board certification and/or professional society membership. These standards could be met by minimum hours of service to public-sector patients and the uninsured, by public advocacy work for universal access to medical care, or by other activities publicly advocated by each specialty. Public service activities should be tracked and reported, like continuing medical education hours.
The question for physicians (now) is this: Who are we?
References: Congressional Budget Office, "Updated Estimates for the Insurance Coverage