No Health Care


Three recent published articles about the health care crisis caught my attention while surfing the internet.

First, in the article “Forget good; any doctor is hard to find,” a mother laments because she has to drive all over the Coachella Valley in California to find a doctor to evaluate her 2 year old child with a cough. After going to four different providers, she finally went to the emergency department and was seen by a PA because “a good doctor is hard to find.”
I sympathize with her, but if you read the article, it wasn’t that she couldn’t find a physician to see her child (although a couple of the clinics she went to didn’t see children under 3 years old). The problem was that the physicians that *were* available didn’t take her insurance and she didn’t want to pay out of pocket. The article did not say what type of insurance she had, but my guess is that the insurance was MediCal. Given the low payments MediCal makes to physicians, fewer and fewer physicians are willing to accept it. This mother’s ordeal just highlights the fact that universal coverage doesn’t mean much if no one takes your insurance. Kind of like having $10,000 worth of Japanese yen in your pocket and trying to buy a hoagie in downtown Pittsburgh with them.

Another article that caught my eye
was from Canada, where protesters were planning a sit-in at a hospital emergency department because the hospital will longer perform emergency surgeries and will instead ship the emergency cases to another hospital across town. If there is no incentive to provide emergency surgeries, then it is difficult to force a hospital to continue performing them. The article also notes that several other hospitals in the area have already stopped performing emergency surgeries – also deciding to ship them to different facilities. As fewer and fewer facilities perform emergency surgeries, more and more emergencies will pile up. At some point it will be a case of “when everything is an emergency, nothing is an emergency.” Think that care will be good?
But at least the care is free … right?

Then finally was the article from Florida’s Gainesville Sun, titled “ER care for kids ‘stinks’“.
Fewer and fewer specialists are willing to take call from the emergency departments and there is difficulty finding emergency specialty care for children. The unfunded federal mandate EMTALA is backfiring. If you’re an “on call specialist”, EMTALA requires you to provide emergency stabilizing treatment for any patient that needs your services – even though many patients needing emergency services will never pay their bill and can sue for millions of dollars if the care they receive is not deemed adequate.
So specialists just stop taking emergency calls. Now emergency physicians treating people with emergencies scramble to find emergency specialist care when in some subspecialties, there is little or no emergency care nearby. Neurosurgery, obstetrics, and psychiatry are just a few of the specialties in very short supply in some states.

In trying to legislate “perfect” and “equal” care for all, now more and more people are finding that there is “no” care for anyone.


  1. I vaguely remembers someone mentioning something about: inexpensive, high quality, and fast, pick any two…….

    William sends with apologies for the lack of link (http is just not my thing)

  2. Unable to comment on the whole article but as you should know, surgery has it’s best outcomes when performed by surgeons who are experienced in the procedure and have carried out a large number of these procedures. Therefore after being stabilised in the receiving hospital does it not make sense to give the patient the best chance of survival using the most experienced staff? The ambulance staff soon learn when to bypass or not bypass the District General Hospital and go straight to the teaching hospital. This is the beauty of a system where hospitals do not need to show a profit and prevents the unnecessary duplication of services by centralising skills and resources. Do you not have a similar system where smaller hospitals will stabilise then transfer patients for definitive management?
    Health care in Canada and the UK is not, never has been and never will be free, someone has to pay, it is just done through the tax system.

  3. Grumpy,

    we do have a tiered trauma system that stabilizes and refers but that is not from one hospital in town to another, it is from a rural hospital to a larger center almost always. In a city with a large trauma center the flow is directly to that center and there is no referral.

    The issue I think WhiteCoat is getting at is needless transportation within a city for ‘standard’ emergency surgeries like an appy or an SBO. That submits an unstable patient to the risk of transport, which is a real risk.

    EMTALA in the US would be fine if there were funding and liability protection for providing these mandated services. Our EMS system started well because of mandates WITH funding, and is now crumbling due to mandates with NO funding.

  4. Given the low payments MediCal makes to physicians, fewer and fewer physicians are willing to accept it. This mother’s ordeal just highlights the fact that universal coverage doesn’t mean much if no one takes your insurance.

    This will be addressed by mandating that physicians must accept any and all forms of payment from any and all carriers.

    As I recall, when Hillary Clinton was working on her super-secret health care committee in the early days of her husband’s administration, one of her mandates would have been to outlaw the freedom to self-pay.

    With these two mandates in place, we’ll all be in a world of hurt; there probably won’t be any physicians left in practice. 😛

  5. I’ll betcha this chick didn’t do something simple like check with Medi-Cal to see which providers in her area took that “insurance”. It’s never a huge secret which providers you can see. Driving around looking for a doctor and arriving in random lobbies demanding to be seen isn’t exactly how you’re supposed to establish a primary care-type relationship.

    • That is a lot of assuming… I am just saying. You make the mother sound stupid instead of, oh I don’t know, DESPERATE?

  6. I’d much rather our system where everyone (even those in receipt of benefits) are taxed at source and thus contribute towards mecial care. Some people choose to opt for private medical care cause it affords them a private room with a tv, not that much else extra, maybe a faster turn around….dunno, never subscribed to it….I’ve had 2 live births, 1 miscarrige, 3 minor back ops, 2 minor/1 major gynae ops, 6 mths consistent physio,plus assorted x rays, ct scan, mri scan, and all associated consultancy, sleep clinic eeg, ecg, blah blahblah…, asthma clinic etcetera……………I pay for my drugs, via a prescription. A prescription costs me about £7.50 per item per month.

    I’d be bankrupt in the US.

  7. nurse k i read the article and she states she did check out the urgent care centers that would see her child but seemed to have gotten tangled up in some bureacracy..she did have a primary who wasn’t available. I don’t think calling her chick was exactly endearing either. And how can you assume she was “demanding?” were you there? I was on medicaid briefly in my 20’s due to some loust circumstances and I can tell you it is a demenaing and frustating experience. Back off chicky…you need a little r and r.

  8. R and R sounds good to me! My latest vacation request was not approved, however.

    PS If you ever want to be seriously bored out of your skull, feel free to email me and I’ll tell you about the stuff I’ve done for the un/underinsured in my department. It’s not often that a non-management staff nurse presents her work (thought up and designed herself) to the leaders of her organization. Also, I will top any and all of your poverty stories if you so desire.

  9. honey, no way i’m getting into a pissing match with you although the best story I will share with you is working in the city hospital (pre-emtla when patients were dumped because of no insurance) where we had a non insured non employed epileptic who was constantly admitted for uncontrolled seizures…surprise surprise. We got him a job passing water in our ward (30 men in one, 30 women in the other and on bad days a few by the elevator) and in return the hospital dispensed his epilepsy meds. a win win.
    You couldn’t top my stories if your life depended on it.

  10. My neck hurts from this tennis match of witty words! At this writing, it looks to be ad-in, midwest woman’s service… But tradition has it that Nurse K will take the Final Word.

    And why am I here? Ah. Yes. Well, first I wanted to say that I, too, resent the constant “this chick” tough attitude. “Resent” is too strong a verb. I *tire* of it. It seems to be popping up everywhere, this badass easy copout of a way of interacting.

    I think the author of the first article WhiteCoat refers to must be considered as much a journalist as a mother, and in neither instance is she “this chick” who lacks the intelligence to phone around or go online to check provider/insurance compatibility. As a journalist, she knows how to set up the situation to be its most provocative –see how it brings stereotypers out of the closet, zoomzoomzoom?

    And… I am trying to understand the reality behind the third article/instance, wherein emergency on call specialists “just stop taking emergency calls”! Actually, the reality, I *get* — but is there no legal recourse should such a physician pull that crap? I know many of you don’t consider it crap, but as a Mere Mortal Non-Medico, I do. I cannot imagine the frustration in trying to treat an emergency patient in need of specialty help, and having no one answer the phone…

    And yes, all of this, the more I learn of it, makes me admire those of you who continue to go about the job in a dedicated manner, remembering not to denigrate those patients who sometimes must seem like walking symptoms of the sick system.

  11. WhiteCoat… Sorry you’re incorrect about the mother being on MediCal. Here’s a note at the end of her article which will say she’s not…

    “Melanie Fine lives in Indio and is a chemistry and physics teacher at Coachella Valley High School. Reach her at cantormel AT”

    If she’s a teacher in the CA public schools you can bet, she’s in the teacher’s union and she’s not on MediCal.

  12. This “chick” is responding. I wrote the article “Forget good — any doctor is hard to find” based on an experience I had trying to get my son seen by a doctor. To set the story straight, I am neither ignorant nor on MediCal.

    I am a high school chemistry and physics teacher, and have a chemistry degree from Cornell University and a masters. My insurance is Blue Cross POS. Please, before making assumptions about what happened, read my article to get your facts straight. My son has a primary care who was out-of-town. The on-call doctor wouldn’t see him either. It was only then that I pursued urgent care. As I wrote in my article, I had a list of urgent cares provided by my insurance company that would see my son. Not one of the urgent cares on that list would see him. It was then that I had to go to the emergency room, which I find very unfortunate because I don’t think emergency room specialists should be spending their time on non-emergent cases.

    The only major mistake I made was not calling in favors from my doctor friends. I didn’t think I needed to, because at the time, I assumed the system worked. My son had a terrible cough that was getting worse, and I just needed someone to listen to his lungs. The fact that it grew into such a quest speaks volumes about the system, doesn’t it?

    • If you read my comment about your article, I never called you ignorant nor implied such.
      I raised two issues:
      1. There were physicians available, but they didn’t take your insurance and you didn’t want to pay out of pocket
      2. To use your insurance, you had to run through a gauntlet to find care for your child
      Whether your insurance was MediCal or BlueCross is irrelevant. The crux of the problem is that “insurance” that doesn’t allow someone to get timely care for their family really isn’t “insurance” at all.
      It does speak volumes about our system.
      Remember the problems you had as our system inches closer to one in which *everyone* has “insurance” and nobody has to pay for their care.

      • I’m sorry. I was replying to NurseK’s assumptions. I agree with you. Our insurance is not insurance when it becomes an obstacle to receiving appropriate care.

  13. Ironically, WhiteCoat, your push for tort “reform” moves us inexorably closer to the kind of universal care that results in these situations.

    • A free market system will not move us closer to universal care. It will move us farther away from universal care. You are making unsubstantiated and illogical statements regarding a situation about which your comments demonstrate your lack of understanding.
      Tort reform boils down to this: Perfect care or available care – pick which one you want.

      • If tort reform boiled down to that California would be flush with physicians – as it has had a draconian system in place for decades. Try again on that.

        There is nothing “free market” about legislators arbitrarily deciding the value of an injury. But when you take away people’s right to recovery, and make vague claims about promising more physicians and specialists everywhere if you get your reform, and you don’t deliver, you are treating healthcare as a right. You sell tort reform as promising more care and more care and more care. That makes people expect it when you get them to pass it. Problem is, you can’t deliver because no specialist really wants to go to rural BFE to practice. So people naturally ask themselves why they aren’t getting this “right” after they gave you protection.

        Nothing illogical about that conclusion. The long and short is that unless you physicians stop doing your insurers dirty work for little to no benefit to you, and start focusing on your manner of compensation, you’re going to get your tort “reform”, because along with universal health care we’ll get a workers comp style no fault system. Then you can rave about how great European systems are because you’ll have first hand experience!

  14. Pingback: Univerasl Coverage, But No Physicians? « The ACUTE CARE Blog: Non-Urban Emergency Medicine

  15. By the way, you often hear physicians commenting about a “shortage” of physicians if you don’t do this or that for them. How many physicians, and of what type, constitutes an appropriate number? Has this been determined so that the declaration of a “shortage” can actually mean something?

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  18. If I’m getting the general gist of your comments on the Canadian hospital issue correct, you’ve quite wrongly misinterpreted the article.

    The decision was not made by the hospital in question; the article states clearly that it was made by “the Winnipeg Regional Health Authority.” So what we have here is not one hospital dumping on another, but the management of a group of hospitals trying to concentrate its emergency surgery services in one of a group of hospitals in an area. Second, there appear to be plausible reasons for this: their surgeons tend to be specializing further, presumably meaning that concentrating them together gives a greater likelyhood that any random patient rolled in off the street will get the best doctor for his problem. That same management has also done this in other areas previously, though it’s not clear that they examined whether or not this works before implementing it in this particular case.

    Responding to another commenter, the “needless transportation within a city for ’standard’ emergency surgeries” thing may or may not be an issue; I do note that they said “re-route,” implying that this applies only to patients already being transported.

    And one last minor point: there was only one “protester,” a local MP. I’m wondering if he wasn’t just doing this as a publicity stunt.

  19. ALLL that I really have to say, with great certainty, is that I want the right to choose for myself. I don’t want the government taking over every aspect of my life! I am a recent cancer survivor. The company that I work for, God bless them, helped me by keeping me on their insurance two years ago until I was done with treatment. I have returned to work a little over a year ago, surviving surgery and chemo for colon cancer that we, as a community, came together of our own accord to make it work.
    Approximately half of my paycheck each week goes to my insurance costs (my health as well as life that I had bought into before cancer) and I am GRATEFUL and GLAD to pay, because I know the kind of treatment that I am getting (life saving!) vs the young, single mom at my job who has cancer throughout her body and two young children WHOSE on medical (and who runs that, huh… isn’t it the government?). They won’t even give her her test results half of the time, because THEY HAVEN”T BEEN PAID FOR! By the time she is really treated (which by the way, she is being cared for not by an oncologist but a family MD), she might be dead! She is presently at stage three… for about a year.. If they can’t fix that care, why would I want them to take over mine?
    I am just saying. You decide.

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