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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?

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.

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

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Comment Preferences

    •  OK It Is Clear You Know More About This Topic (9+ / 0-)

      then I do by like a factor of 100. But I have been thinking about something pretty similar if not interrelated. I was thinking at starting on a smaller scale. We know that folks that live in lower income areas, minorities, single mothers, less education, recent immigrants have far less access to health care then the yuppie (which I am) in the burbs. They are the people that don't get treatment when something can be treated. Those that go to the Emergency Room. Those that suffer in silence.

      It would seem we have pretty detailed Census information and we know where these people live, and they tend to live in areas where all those around them are in similar situations.

      We also I am pretty sure know that most might not have access to a car, and traveling more then say three miles makes it hard for them. We pull out maps and start to dot the countryside when clinics ever three miles (or whatever it needs to be).

      We start by opening up free clinics in these area. Heck off them a meal if they need and/or want one. We give them free passes for any public transportation they may need to get to and from them. We give them what they need to live a long, healthy, and productive life.

      They stay open unusually hours so a person working "strange" hours can get there after they get home from work. On the weekends.

      Anything and everything to make the process as simple and painless as possible. We learn from these and start to expand them 24/7 to eventually cover as much of the United States as possible.

      I mean don't tell me we couldn't do this if we really wanted to.

      "In a time of universal deceit, telling the truth is a revolutionary act." - George Orwell

      by webranding on Thu Dec 31, 2009 at 04:33:02 PM PST

      [ Parent ]

      •  Yeah but (7+ / 0-)

        this is the country where moving voting day to a weekend, or extending the voting period, is met with responses like "I don't want those people voting in my elections!" This country is not programmed in a way to make things +easier+ for the poor or working poor. In fact, it seems quite happy to do the opposite. :(

        •  I Don't Disagree, What Is Suggested In This (6+ / 0-)

          Diary, if possible, I would be behind 24/7 as it has been stated. But IMHO it would be such a change that it would be a total shock to most of the public. You think a public option that only maybe 5-8 million people used caused problems, try this.

          Although I am unhappy about a lot of things in the health bill, the clinics is a huge win. I almost don't want any of us to talk about them so they can get passed without the right getting what they mean and totally freaking out.

          "In a time of universal deceit, telling the truth is a revolutionary act." - George Orwell

          by webranding on Thu Dec 31, 2009 at 05:16:29 PM PST

          [ Parent ]

          •  :) .............. n/t (1+ / 0-)
            Recommended by:
            •  Not Sure What That Means, But An Example (6+ / 0-)

              I always worked for small companies. Pretty darn progressive and liberal. Health care was something they took very serious. First it was the health of their workers. Second, much larger companies if they didn't have good benefits might hire us away.

              Flu shots. Nurses came to our office to do it. Basic check up, same thing. My offices had folks coming in to give us a massage before Google was a dream. It was done for a selfish reason. I might have billed our clients $150/hour. I could walk a few feet to get a flu shot and it take 10 minutes or I could get into my car, stressed out, and drive around for a few hours into Northern Virginia traffic.

              Also, a healthy employee is a good employee.

              The person that washes my dishes after I eat a meal out (and I know I am preaching to the choir here) doesn't deserve any less. We need to start to grasp these pretty, at least IMHO, pretty basic facts.

              "In a time of universal deceit, telling the truth is a revolutionary act." - George Orwell

              by webranding on Thu Dec 31, 2009 at 05:29:02 PM PST

              [ Parent ]

      •  Uh...what? (0+ / 0-)

        I'm glad that you agree that free clinics are a good idea. Beyond that, I have no idea what you're talking about.

        Please take this as a friendly admonition. Try slowing down and form the concept a little more clearly before you start typing. There is nothing wrong with your prose, but I have no clear notion of what your point is. You outline a lot of programs I'd like to see, too, like public transit passes and round-the-clock clinic hours, but you don't give us a notion of how to get there from here. That's what I'm gleaning these comments for, new ideas about HOW to get the stuff we all want.

        Thanks for reading and letting me know that the piece got you thinking! If we keep beating on it like this, sooner or later we'll come up with a strategy that will get us what we all want. Please read my blog and comment again!

  •  Things that make you go" Hmmmm?" (7+ / 0-)

    Why not indeed.  The back door to universal care.  Just might work.

    "My brothers keeper"

    by Reetz on Thu Dec 31, 2009 at 04:22:09 PM PST

    •  We need more Physicians Assistants to run clinics (0+ / 0-)

      They should have a program to completely fund promising college grads through the 2 year PA programs- if they are willing to work in their communities for a few years. (2-4 years)

      Physicians Assistants are the hard workers that keep most free clinics running.

      Everybody is automatically enrolled in Canada's health plan. You don't "miss a payment" because THERE ARE NO BILLS.

      by Andiamo on Sun Jan 03, 2010 at 06:12:00 AM PST

      [ Parent ]

  •  I've come up with something similar... (3+ / 0-)
    Recommended by:
    khughes1963, webranding, kyril

    Which is the final section of my 6000 word ongoing essay giving the reasons why I oppose the current HCR bills that are now pending conference committee.

    If someone wants to read the whole thing, it's here, Healthcare beyond partisanship

    With this as an alternate:
    There is a better approach to universal health care

    The argument that seems most compelling for passing this HCR law is, "We can't go on like this, and this bill  is a first step that must be taken." I disagree, as does Howard Dean, someone who is just removed enough from politics to view choices objectively.   There are different approaches, that do not build on the current distorted profit based political model. There could be a parallel system of single payer, that would transform a part of every emergency ward into a federal system for providing basic health care.

    Just as the VA preempts state licensing law for it's professional staff, such a national system could also do so. Rather than malpractice prevention being in the judiciary, with it's acknowledged excesses, there could be a better system, where those who report malfeasance would not fear their own legal liability. It would be a blow to plaintiff lawyers, who would be replaced by a system of experts, who in the process of reducing poor medical practice could also foster rational procedures.

    This provision would hurt a major Democratic constituency, but there would be other aspects of this program that would sacrifice the interest of traditional republican supporters. This is what bipartisanship really means, sacrificing party interest for the sake of the country.

    This parallel universal system could work incrementally, growing with the increase in providers, eventually incorporating existing successful non-profits such as Kaiser Perminante into this network. It would actually realize the ideals of this current bill, cutting waste, promoting evidence based medicine and expanding coverage-- without trying to do the impossible, which is to pander to the existing powerful interests that are perpetuating our current health care defects.

    This would be transformative and actually politically possible. Professionals in this system would be chosen by aptitude, responsive to demand for specialized training. As an example, free medical education would be available to those willing to dedicate their career to this system. Unwarranted escalation of professional educational requirements, something that creates artificial shortages, would be tackled frontally, to the benefit of consumers.

    It would be a parallel and effective means of providing health care to all
    Actually as this evolved it would go beyond single payer, to actual british style socialized medicine.  The savings from billing, coding, negotiations with payers would be dramatic.  

    It would not be perfect, but it would provide medical care, and perhaps the illusion that more such care is better could be dispells.

    And it would provide the laboratory for all of the innovative types of practices that are only a dream in the current proposals.

    •  Have you see the web site? (0+ / 0-)

      People who hold up Kaiser as a model rarely have.

      They have so many political connections, though.

      Henry Kaiser was friends with Richard Nixon.

      Everybody is automatically enrolled in Canada's health plan. You don't "miss a payment" because THERE ARE NO BILLS.

      by Andiamo on Sun Jan 03, 2010 at 06:13:49 AM PST

      [ Parent ]

  •  Interesting stuff (5+ / 0-)

    This is so new an idea that I'd love to see a few more links or references in order to rec it.  This diary probably deserves a huge rec., and the only reason I'm holding back is that I don't have the expertise to evaluate your statements (and the discussion on healthcare has been so heated lately).

    Thank you for this.  If it doesn't get immediate attention, it might be a good Rescue nominee.

  •  I have no idea if this is remotely practical (4+ / 0-)

    but you've made a great case for a great need.

    [message deleted] - Barack Obama

    by Bob Love on Thu Dec 31, 2009 at 04:37:42 PM PST

  •  Do these free clinics do surgery (6+ / 0-)

    trauma care, intensive care, etc? If not, they are a part of the solution - a big, important part - but it isn't reasonable to say that they can get all of their medical care there. In addition, people shouldn't be up the creek if they travel to another location where there doesn't happen to be a clinic. One reason most developed countries have universal health insurance schemes of some kind is that it gives people more freedom and flexibility.  And hospital care is, to be very clear, where most of the cost of medicine lies.

    Perhaps some hospitals can be converted over time but building new facilities would cost a fortune.

    There are some free hospitals in the country, but to my knowledge not that many, and many are specialized (St. Jude and Shriners both serve kids, for example).

    I was paid to post this comment by my cat, but he's a deadbeat.

    by decembersue on Thu Dec 31, 2009 at 04:41:04 PM PST

    •  See That Is A Very Good Question (3+ / 0-)

      In my other comment here I view (in my vision/world) them as free primary/preventive care. I just don't see how you can do away with the need for coverage if a person has a heart attack, needs surgery, or is about to give birth.

      But I feel like this could be a start. I have joked (and I don't think it is funny) I am pretty sure I could run a health care plan, make money, and not gouge people if you gave me time. Cause I would focus on people not getting sick in the first place, which costs a heck of a lot less then trying to treat people after they are already really sick.

      "In a time of universal deceit, telling the truth is a revolutionary act." - George Orwell

      by webranding on Thu Dec 31, 2009 at 04:47:45 PM PST

      [ Parent ]

    •  The City of Hope, Duarte, CA, US (5+ / 0-)

      They are a specialized facility that treats people with cancer primarily, but from their beginning in 1913 as a TB sanatorium they have only one criterion for admission: ability to benefit. Ability to pay has not and will not be a bar.

      There are other places like this throughout the country. I believe there is a hospital specifically for lung diseases in Denver, Colorado that also started off as a TB hospital.

      I have to give major props to CoH: they gave my husband one more good year of life as he struggled with multiple myeloma. He had a year complete remission. And we were both broke and had no health insurance.

      The next OneCare Happy Hour will be January 29, 2010.
      Akemash'te omedetou gozaiimasu!

      by Pris from LA on Thu Dec 31, 2009 at 05:14:23 PM PST

      [ Parent ]

      •  Not many other places like that! (0+ / 0-)

        But there are some. So your saying "there are other places like that" is accurate.

        Its good that free clinics exist. For young people, they are often the only healthcare they need.

        Older people, though, its a completely different story.

        Again, the emphasis is on solutions that don't solve, that in fact, hide, the very real problems.

        Everybody is automatically enrolled in Canada's health plan. You don't "miss a payment" because THERE ARE NO BILLS.

        by Andiamo on Sun Jan 03, 2010 at 06:03:25 AM PST

        [ Parent ]

  •  I can hear the 'Pub reaction: (4+ / 0-)

    "What's next?  Free Huey?"

    Finally, some new songs up at da web site!

    by Crashing Vor on Thu Dec 31, 2009 at 04:44:54 PM PST

  •  Mandate money vs. Free Clinics? (5+ / 0-)

    I imagine that all the money going towards the mandate to support health insurance companies could go a long way to providing free clinic services to support the needy. In free clinics there would certainly less "insurance" risk profits wasted because the services would be provided to those who have a present and clear need...


    by FakeNews on Thu Dec 31, 2009 at 05:04:41 PM PST

    •  Clinics only for poor urban dwellers. (0+ / 0-)

      Few others can afford to drive hundreds of miles or sit in a waiting room for a whole day waiting for their number to come up while trying not to pee in their pants.

      Everybody is automatically enrolled in Canada's health plan. You don't "miss a payment" because THERE ARE NO BILLS.

      by Andiamo on Sun Jan 03, 2010 at 06:04:52 AM PST

      [ Parent ]

  •  This is a great, great piece. (2+ / 0-)
    Recommended by:
    khughes1963, wayoutinthestix

    Obviously, apparent lack of political will is the biggest hurdle.

    But I just love the "wedgieness" of it.  Both in terms of the inexorable replacement of our broken system and the skidmarks that would form in the Rs' bunched panties.

    I've tipped and rec'd and wholeheartedly wish that it was getting more eyes.

    I've also saved on my hotlist for future reference.

    Thanks for this diary.

    This machine kills fascists!

    by Zotz on Thu Dec 31, 2009 at 05:29:07 PM PST

  •  This concept is truly brilliant (2+ / 0-)
    Recommended by:
    khughes1963, edbb

    You say:

    The hardest change in mind set may be letting go of the idea that health care should cost a lot of money.

    That's it, isn't it? In a nutshell. If I'm not paying a fortune, what I'm getting isn't good.

    Related to "My BMW convertible is better than your VW Jetta." Well -- maybe not, both get us to the same destination.

    Maybe free health care is as good as super-expensive health care.

    This health care system is a moral atrocity. Dr. Ralphdog

    by AllisonInSeattle on Thu Dec 31, 2009 at 05:53:57 PM PST

  •  You should read the manager's amendment (0+ / 0-)

    to the senate bill. It has $10 billion allocated to community health clinics to develop more of them, train and hire more primary care providers, coordinate with public hospitals, and all sorts of other good stuff.

    There are provisions for residents to do their training at CHCs and incentives like tuition forgiveness for people who work at them.

    These nonprofit clinics aren't completely free for everyone. They must take medicare, medicaid, and SCHIP patients, and they take everyone else on a sliding scale based on ability to pay. Insurance in the exchanges is mandated to reimburse them as if they were in network, and other insurance plans already reimburse as they would normally. They get negotiated drug prices (based on the VHA system) and they help connect people with drug company patient assistance programs. They offer dental care and mental health counseling in addition to primary care.

    This is a network that already exists. It just needs to be expanded, and the bills in the house and the senate both do just that - all in a way that does an end run around the insurance industry.

    •  Massachusetts gets money from (0+ / 0-)

      mandated insurance for clinics.

      No reason to think that nationally it would be any different. Money, even deductibles of HDHPs or money from their paired HSAs goes a lot further spent at PA-staffed clinics than at doctors.

      Everybody is automatically enrolled in Canada's health plan. You don't "miss a payment" because THERE ARE NO BILLS.

      by Andiamo on Sun Jan 03, 2010 at 06:16:30 AM PST

      [ Parent ]

    •  I will! (0+ / 0-)

      You're right. I really should do more research than I do before I start shooting my mouth off. The trouble is that I'm a bloviating gasbag by nature and it's hard to be more scholarly.

      Thanks for the tip!

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