By Jean-Pierre Forage, M.D., F.A.C.S.
Much political hay has been made over the fact that 45 to 50 million
Americans are without health insurance. Little recognition is given to
the fact that care was provided to these patients without compensation.
While it seems to be politically popular to call for healthcare reform and
find new ways to pay for this in the form of new taxes and restructuring
government, one fact remains: patients in this country have always been
cared for by physicians with or without payment. In this current economic
crisis I would submit to you that we continue to allow providers to care
for patients without the government compensating them, rather than
generating some new type of Medicaid for the masses or fully a subsidized
health care plan. I would suggest that we leave the current system in
place, with the following provisos:
1) Physicians continue to care for patients as they have, and all patients
below a certain income level would be treated with no charge to the
2) To compensate the physician caring for these patients we would simply
allow them to take their reasonable and customary charge, reduce it by
50%, and then submit this charge on their income tax as a tax credit.
3) No physician would be allowed to actually receive a tax refund beyond
what they would have owed in tax, so the best a physician could do would
be to pay no taxes on money generated elsewhere in the practice.
It is often stated that patients show up for treatment sicker and further
along in the course of their disease because they don’t have insurance and
thus wait to the last minute to present in the emergency room settings
with more severe complicated illnesses that require more services and
protracted stays with higher risks of complications. By freeing the
patients from the burden of worrying about how they will pay for this
care, hopefully we will see the patients sooner and, in fact, make it less
expensive for all parties concerned and have a higher quality of outcome
for the patient. It would be important to pick a threshold number at
which all people earning under a certain level of income (who are not
already eligible for Medicaid or Medicare) would be the only ones eligible
for this program. I submit that this level could be consistent with the
current tax schedules for paying income tax. Additionally, we could give
an incentive to employers to provide insurance to employees tax free.
The question of how this program would be administered is simple. The
physicians would continue to care for patients, submit their claims
directly on their tax return. They would be monitored by the Internal
Revenue Service, and thus oversight would be criminal penalties should a
physician falsify a claim. Quality could be controlled by the fact that
physicians already have peer review and oversight, both through their
medical boards and hospital committees.
Some would argue that this appears to be a tax break for physicians who
don’t need a tax break, as they are relatively high wage earners in this
country. I would submit that this, in fact, is not a tax break, but an
actual small compensation for services that are currently being provided
at no charge, and would continue to be provided at minimal charge, for
amounts less that any program that could be created through government
For argument’s sake, let’s just do the math. There are approximately
300,000 physicians in this country, and the average income for a physician
in this country is somewhere south of $150,000. If we were to take all
the physicians in the entire country and say that they all participate in
this program and every physician provided enough free care to pay no
income tax, we would then say that the country would loose the revenue of
all 300,000 physicians’ income tax amounting to 15 billion dollars. If,
however, we were to divide 15 billion dollars into 50 million patients, we
see that the care being provided would be at the cost of approximately
$300 per patient annually, far less than any program that could be
administered by the government. In reality, it is unlikely that all
physicians would participate, so some revenue would still be generated for
the Internal Revenue Service by physicians not participating in the
program. It is also likely that physicians who participate would more
commonly overshoot the free care they were providing, and thus be giving
care without compensation.
Also, patients would gradually start to show up earlier and be less sick,
so the actual charges generated by the physician would continue to go
down. Thus, this program would have a built in quality improvement factor
and an overall cost lowering feature.
I have presented this idea to several political campaigns and to several
organizations, both legal and medical. Unfortunately, most of the time it
is met with comments such as “this does not create new jobs”, or “this
looks like a tax break for doctors”. As has been elucidated above, this
is a sound program that would provide a service that would cost less than
the government could ever dream of providing, continue our current system
of health care which remains the best in the world, and remove the stigma
that some feel is attached to an un-insured patient, thus resulting in
overall better health for the American population as a whole.
Everyone wants to think outside the box and wants to come up with the next
new program, but sometimes the answer stares you right in the face. I
believe the time has come to do what is right and not what is politically
enticing. I would submit that this is the former, not the latter.