Physicians

PHYSICIANS: How to easily increase access to care, by Eric Novack

NovackEric Novack is an orthopedic surgeon who went to medical school in liberal San Francisco, but is now practicing in the red state of Arizona. Eric has been sparring with me and others in the comments on THCB, and also has his own weekly radio show. It’s on a station called "960 The Patriot" — and you can guess that it’s line up is a little different than San Francisco’s 960 The Quake, which is our local Air America affiliate. Eric’s weekly show is very well done, and I recommend that you head over there to take a listen to his archived shows. Some of you might perceive a bias in his guest line-up, and Eric has strong opinions on policy, many of which I do not share.  But I’m very hopeful that by encouraging Eric to write for the blog, (and we are also planning some podcast conversations in the near future), we can get to some of the heart of the issues about which we disagree. For his first post, Eric starts simply, with an idea to get physicians to provide more uncompensated care.
In what I hope is the first of many posts for THCB, I propose a simple step to increase access to care. The number of uninsured is large. Depending upon your perspective, the number can be as low as around 20 million Americans or as high as 45 million. Of course, you can find those who claim a number larger or smaller. It is a great bit of semantic legerdemain to equate lack of insurance with lack of access to health care. Stating "no access" implies that no care is available and that the government has "abandoned" this group. This is simply not true.

Congress passed a law in 1986 called Emergency Medical Treatment and Active Labor Act" or EMTALA. EMTALA has a variety of provisions but can be simply stated that persons who come to emergency departments cannot be turned away because of an inability to pay. This applies to the hospital emergency department (ED), the emergency room physicians, and the specialists and internal medicine doctors "on-call" for the emergency department. "Emergency" for the purposes of the emergency room is anyone who comes to the hospital– the hospital cannot say– "it is just a cold, so we will not treat you". If someone breaks a leg and an orthopedic surgeon is on call to cover the ED, the surgeon must take care of the problem and the patient including the operation and all appropriate follow-up care.

One of the many problems is that all of this uncompensated care falls back on the doctors– remember that many hospitals are non-profit or have received federal funds that require them to provide a certain amount of uncompensated care.

Let me give an example, (any similarity to any real patient of mine is coincidental…). I am on call for "Arizona Hospital". Bill Jones is brought to the hospital after a fall from his ladder at home, where he was taking down his Christmas lights (it is never too late, is it?). I am called by the ED because Mr. Jones has broken his femur (thigh bone). I see the patient in the ED, he is admitted, and I operate on him at midnight. I finish surgery, the paperwork, and head home around 2:30 AM.  I then see Mr. J for the next 3 days after clinic. After discharge, Mr. J comes to the clinic regularly over the next several months for checks and x-rays and advice and guidance. Total charges for all the work, time, expertise, and liability risk is $5000.

Mr. Jones has his own landscaping business.  He has no insurance.  He never pays a bill.  I cannot abandon his care– it is unethical and against the law (abandonment). I get tired of this happening and stop taking call at the hospital. Losers in this scenario–the physician, the hospital (less coverage), and future patients–insured or not- who would benefit from my expertise.

Here is a partial solution– but first, a brief preamble. Health care system transformation will need to be incremental, not revolutionary– otherwise, the kind of horse-trading and compromises that resulted in the bloated, inefficient, restrictive system of Medicare result.

Here’s the partial solution. Guess what happens at the end of the year when I file my taxes?  Can I deduct the $5000 in bad debt as a "business loss"?  No. By simply allowing physicians to credit bad medical debt from their income (like other businesses can with losses related to products, etc.), physicians would be have a huge incentive to provide a certain amount of care to the poor. It needs to be a credit and not a deduction as a deduction would return only 35 cents on the dollar at best. So, there it is– tax relief to the providers of care for the amount of "free care" provided. 

No new bureaucracy.  Incentives, not punishment

For some more info on EMTALA see this lawyer’s site.

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33 replies »

  1. From a doctor’s perspective who hasn’t yet joined the old boys club – if there is one…, I don’t think most physicians wouldn’t be happy to do our share to help the poor but we want people held accountable. How do we properly identify the working poor when they walk into our clinics. I see too many “poor” people with ring tones, Nike Air Max, and Starbucks (luxury items). The grumble at the high co-pay because we have been trained to make healthcare the last thing we pay for. The uninsured working class cannot get affordable healthcare because each patient – poor or rich just costs too much to process in 2008.
    The government and insurance companies do this all the time. There are a few doctors who will accept a lower fee for their services but oddly enough none of them accept insurance or take medicare or medicaid… Why??
    I agree with the above, the government will never give a tax credit but making it cheaper for physicians to practice would help.

  2. Bootstrapping, conservative perspective outlines that NAFTA is good. Well NAFTA is set to be extended to the Trucking Industry. Why not extend it to docs? That way docs dont have to inconvenience themselves with nobly not abandoning a patient who cant pay.
    I think docs are overworked and overextended. They should be given a break, and the market of providers can be increased.
    Personally, I go overseas, but would love a free trade arrangement that allowed those services to be provided here.

  3. I read all of the above with great interest. I wonder how many who read this whole thread missed the major point at the beginning…..The doctor had no choice but to treat the patient in the middle of the night.
    He then does not get paid.
    This is different than any other business that does not get paid.
    Charity when it is either expected or compelled is another form of slavery.

  4. No one has pointed out a gaping logical hole in this proposal.
    To wit: Giving Dr. Novack a $5000 credit is not in any respect different than the governnment paying Dr. Novack the money.
    People tend to assume that tax credits, deductions, etc., are a painless way of getting something to happen but in fact every single one cuts into tax revenues and affects public budgets in EXACTLY the same way as if the money were collected & then spent.

  5. Yeah, my thought on this is that it’s hard enough to maintain a fraud-free system where you actually have trained people reviewing claim forms. How easy would it be to commit fraud in this system?

  6. Dan,
    You forgot to say how much your Blue Cross coverage costs. Tell us which Blue Cross plan has a dependent coversion priviledge that allows children to move to 43 states and keep their coverage.
    Please Dan tell us the state of your Blue Cross plan and if it is individual or group coverage from an employer.
    Liberals never discuss costs for insurance they only scream about deductibles.

  7. Thanks, Eric
    Your new suggestion: that “with some kind of ‘proof of hardship'”, those without insurance could get care “at no cost to them” sounds great!
    But it’s not in your original post, or anywhere else in your comments on your proposal.
    I like the idea that ideas can evolve through dialog on blogs, and the conversation here is very productive. I hope that in your future posts on this proposal or other topics, you’ll include this key element of your evolved proposal just as you stated it here: free care for those who need it.
    That element is obviously what makes the proposal “increase access”. Indeed, now that this element is out in the open, one wonders: what other ways could we fund this key element (free care for those that need it) which would be most efficient and fair?
    – Dan

  8. Dan- A presumption, I believe, is that the main reason people do not go to the doctor for routine, preventative care, is economic– those without insurance cannot afford to go to the doctor, are afraid of big bills, therefore end up with much worse, more expensive medical problems.
    If that same group knew that, with some kind of “proof of hardship”, that the care would be no cost to them, people would be more likely to seek out simple, efficient, preventative care.
    You are correct in that this is not how things are now– the post is a proposal for how to increase access to care.

  9. At the end of the day, no one will work for free–certainly not doctors–any rational plan for health care reform must fairly compensate those individuals (doctors, nurses, technicians, and allied health practitioners) who have made it their life’s work and career to take care of sick people.

  10. Eric,
    You still haven’t answered the key question: how does your proposal of tax credits for doctors help achieve the title of your post: “How to easily increase access to care”?
    I’m repeating myself from yesterday, but you still haven’t answered: your idea is great for doctors, but does nothing to help those who cannot go to the doctor OR the ER because they are uninsured and don’t want to be forced into bankruptcy. Your original post is based on the myth that people get free care in the ER. That’s simply not true: regardless of insurance status or ability to pay, EVERYONE gets billed after seeing the ER, and everyone goes to collections if they don’t pay.
    -dan

  11. Spike- I sense that the essence of one prong of the “pro-medicare for all” solution has to do with overhead calculations:
    The magical 3% overhead number (administrative cost/ benefits) appears to come from a Kaiser Family Foundation study from 2003 (author Merlis)-
    There are reasons that can account for much of this:
    1. elderly populations are going to have more spending per enrollee than younger, healthier populations
    2. inadequate oversight or an actual lack of administrative oversight (to reduce the fraud many THCB readers feel doctors are guilty of) will make it seem more efficient.
    This is a summary from a Heritage Foundation article available here: http://www.heritage.org/Research/HealthCare/wm285.cfm
    KFF report available here: http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14376
    Also, remember that I am not a proponent of the status quo– health care currently is no where near a “free market” or even close. I will agree that we currently have a broken system, but do not put my view as continuing the present healthcare/ health insurance environment.

  12. Well, we currently have the worst of both worlds, right Eric? I mean… are you saying that we don’t have a system of yearly lobbying campaigns where drug companies and other groups lobby to get certain procedures covered, etc.? We already have most of the negatives you discuss from Medicare, but none of the positives of Medicare for all.
    Yes Medicare does have a lot of codes behind it (you neglect to mention that no single provider has to know anywhere near all of the regulations), but so does every private insurer out there. The private insurers do the exact same things Medicare does, only they do it worse and they do it differently from everybody else meaning that providers are forced to learn 10 different ways of doing things. Competition itself is the biggest producer of bureaucracy and you’re to tell me that markets are going to solve the problem?
    In addition, a couple of the reasons many doctors would be put out of business by lower allowables are 1) doctors expect to become rich and 2) billing to so many different healthplans with so many different regulations requires an army of billers who are eating away doctors’ profits. If doctors only had to deal with Medicare, they could have a small billing office and keep more of the fruits of their labor.
    But none of that was the point of my original post. My only point is that Medicare works better than all of the other payors from a bureaucracy standpoint, so the only explanation I can come up with for why people think it’s so awful is an irrational belief that the government can’t do anything as well as a private company.

  13. “I don’t know how Medicaid works, but it seems to me that you could require doctors to obtain a signature from the patient attesting…”
    Where there is a will there is a way to commit fraud. There is a rationalization among some physicians (and hospitals) to commit fraud “to make up for” cuts in reimbursement and other real and perceived compensation cuts.
    Physician fraud isn’t a trivial problem. Eric’s proposal would significantly add to the problem.

  14. Well put– and, possibly, the question about healthcare– Why not medicare for all?
    Here, of course, is where the opposing camps can provide much data and survey information, etc.
    Issues to consider:
    1. Medicare has 150,000 pages of regulations
    2. Current coding for doctors requires 10,000 different codes from which to choose. The “next generation” coding book (ICD-10) has 40,000 codes from which to choose in order to be able to bill.
    3. The cost of compliance– the figure that medicare runs 3% overhead does not count the additional overhead costs that physicians (and hospitals) must account for to comply with the 150,000 pages (and growing) of regulations.
    4. Medicare effectively is no different than the Canadian system (also known as medicare)– which was just found by the Canadian Supreme court as a violation of people’s rights (give a listen to my “exclusive interview” with CMA president.
    5. healthcare would become a yearly lobbying campaign for coverage for certain procedures, drugs, treatments.
    6. Medicare can work pretty well, unless you have a problem that it will not cover– certain IV antibiotic coverage at home vs. nursing home, inpatient rehabilitation (serious reduction in services has begun– can address in a later post)
    7. If the planned medicare cuts occur to doctors– 30% in non-inflation adjusted dollars over the next 6 years– many doctors will go out of business.
    8. Does/Should everyone get/need cadillac coverage? Does one size fits all for all the US work?
    We have problems in healthcare– everyone who comes to this site knows it… let’s continue the discussion/ debate.

  15. Eric, I was only joking about the belief that people are fundamentally bad. I was cryptically alluding to a kind of Burkean belief that grand schemes are likely to cause more harm than good. I tend to respect that sort of conservatism. Indeed, I’m in sympathy with it. I was basically stealing the line from publius of law and politics (an ex-conservative). His post on the subject is here:
    The market is brilliant at providing cars, but why health care. How do you decide which services the government should provide? Should we all buy fire insurance (by which I mean, not casualty insurance but insurance to pay the fire-fighters)? What about private police protection?
    Spike points out that Medicare works pretty well. If the government is better at this than private health insurers, why shouldn’t it take on the job?

  16. I don’t understand why people are always saying how bureaucratic, wasteful, etc., Medicare is.
    I worked in billing and submitted claims to every payor. Almost without exception, Medicare is the best payor to work with. They have knowledgeable, helpful staff (particularly Medicare EDI, probably the best in the business). It’s the commercial plans that often don’t know their ass from their NM1 segment. When having to resolve EDI-related problems, I was always happy to work on the Medicare-related problems. Medicaid, of course, is the worst by far.
    The height of bureaucracy and waste is the Blue Cross Blue Shield BlueCard program. No government agency could possibly come up with something as wasteful and pointless if they tried. So, why does everybody have so much faith in the markets and private companies and so little faith in goverment-run ones?

  17. Abby- I would call myself conservative– I have heard many descriptions of that term , but have never heard that “most people are fundamentally bad and to be distrusted” used–
    Rather, I would say I believe in the importance of limited government,in benevolent government. I believe in the importance of personal responsibility, I believe in the ability of individuals to act in their own best interests. I believe that this society would be best if individuals acted in their own ethical self interest.
    I do not believe in the power of the government to reliably solve my wants and needs. Benevolence does not mean giving without high expectations in return.
    Anyway… to expand the concept further (seemed quite alot for one post earlier)–
    1. Limitation to tax credit– whether it be medicare rates or an “average reimbursement rate” (which would be higher than medicare).
    2. To encourage delivery of care in certain areas– amount of credit based upon percent of total practice giving uncompensated care– eg. 1/3 of benefit for 10%, just to make up an example.
    This is not, as far as I am concerned, the long term solution. Nor is it complete. However, it would be straight-forward to implement from a legislative perspective (if anything is!), already has bureaucracy (IRS), would immediately motivate the providers of healthcare to expand their practices to include a currently underserved community, and likely make an impact on the current medical liability crisis, emergency room coverage crisis, medical debt issues.
    With Matthew’s continued permission, I will be laying out a proposal for incremental health care system transformation (with all due respect to Mr. Cohn, who I believe sees no possibility in successful transformation incrementally…)

  18. Eric,
    I’ve met plenty of highly ethical doctors, but given the fact that Matthew just posted on how many doctors are making a lot of money by dispensing pharmaceuticals at outrageous prices, I don’t think that physicians as a class are owed any special deference.
    You’re a conservative Eric, right. It seems to be that the basic lesson of conservatism is that most people are fundamentally bad and to be distrusted. In government we accomplish this through separation of powers and bicameral legislatures,n but the private sector needs to be restrained as well.
    It also seems to me that if you do it as a tax credit, the doctors will all file returns which say that X amount of cae cost them $5,000 whereas if the patient had been insured they would have been paid $3,600.
    I don’t know how Medicaid works, but it seems to me that you could require doctors to obtain a signature from the patient attesting to the fact that care was delivered before submitting claims in an effort to cut down on fraud. It’s not perfect, of course.
    The IRS doesn’t audit all that many people, and I’m not sure that it’s best equipped to evaluate what is essentially medical billing. I heard my uncle (a Republican, BTW) talk about his plans for building a home office. He thought that he could save money on his phone bill by using one line for both the home office and the house–and it would all be deductible. I pointed out to him that if he used it for personal use, and the office was attached to his house, he couldn’t deduct the cost. The regs are quite strict on this point. He said, “Ha, the IRS never bothers to audit stuff like that. If there’s no W-2 form, they aren’t going to go after small potatoes.”
    So, basically I’d say that there are too many people who will do whatever they can get away with–especially when they see it as sticking it to the Federal tax man. Those who wouldn’t are probably the people who support universal insurance.

  19. Eric, I think we’ve outgrown the notion that only government endeavors are fraught with waste, fraud and abuse. Take a look at General Motors these days. Or Enron in its heyday. Or any of the “Dot-bombs” that wooed millions in venture capital without a business plan.
    Any human endeavor will be rife with waste, fraud and abuse. Doctors are not above it, any more than anyone else.
    I just don’t buy your notion that doctors will stop showing up at the ER because of uncompensated care. If they do, there will be someone to step in and take their place, and good luck to those who do leave, because any other job they want in medicine, they will have to compete for like anyone else. Unless, of course, they leave the profession altogether. Then they’ll REALLY learn what it means to be compensated inadequately.

  20. Rob,
    I have a BlueCross PPO for my child. I have no deductible. It pays 100% of doctor visits and 100% of surgeries from day 1.
    In contrast, if you have HSA-eligible insurance, it (by definition) only pays out after you have spent $2,100 of your own money (this is from the definition of HSA-eligible insurance at http://www.opm.gov/hsa/).
    So you get NO coverage until spending $2,100 of your own money. That’s definitely better than nothing, but for some people, it’s barely better.
    for more, see Why Healthcare Savings Accounts are Ripoffs at http://66.241.229.23/blog/2005/08/more-details-on-why-health-savings.html.
    >>Of course my child has a father who is licensed so he will never be thrown onto the backs of the tax payers.
    <<
    I sincerely hope you never die or become disabled or lose your job or any of the other hundred things which can happen to a family that are out of your control. If you die, what coverage will your children have? And by the way, I'm not familiar with any "license" which gives you guaranteed health coverage forever. Maybe you could explain what that is – I'd like to get one!
    Eric,
    How does your proposal help the uninsured? As many have reported, the uninsured poor still get billed after visiting the ER. Then their wages get garnished and they are driven into bankruptcy. Sounds like your idea is great for doctors, but does nothing to address the title of your post: "How to easily increase access to care."
    -dan

  21. Apparently, there is little faith in doctors to behave ethically. Since monitoring would be done by the IRS- as it is a tax based reform- do you all believe that doctors fraudulently file returns now? Does your pessimism extend to the general public? Is the public not smart enough to seek out and monitor their own health care? Please, someone show me any large government run program that is not completely fraught with waste, inadequate oversight and bureaucracy.

  22. //whether you have any outstanding medical bills.//
    Hmmm – I wonder if this is cross-hospital since I have outstanding bills from Alta Bates/Summit. That could explain a few things. 🙁
    I’m thinking about trying out Berkeley Free Clinic instead of going to the return visit to Highland. Then I can report on the billing practices associated with Free, lol.

  23. Eric,
    Almost nobody gets credits. How would you avoid massive fraud from physicians who claimed that they had provided a lot of uncompensated care. WOuldn’t it just be easier to bill an insurer or the government? (And if it’s a credit, you are effectively billing the government.)
    gadfly et al.,
    Apparently the quality of care you receive from the hospital also depends on whether you have any outstanding medical bills. Health Care for All of Massachusetts is doing research on this issue.
    And gadfly, thanks for saying that I’m not totally dumb.

  24. dan, on your site you wrote: “These plans are way cheaper than lower deductible plan, for the obvious reason that they are terrible plans because they only pay out after you spend a lot (I think $2000, but maybe $1000) of your own money. SO: they are surprised that POOR people are purchasing CHEAP insurance? Wow, what a shocker.”
    Please dan tell us the insurance you have on your child. HSA insurance on my uninsurable child pays 100% after the deductible, including Rx, to $8 million lifetime max. Also, my child has a dependent conversion priviledge, how about yours? Of course my child has a father who is licensed so he will never be thrown onto the backs of the tax payers.
    HSA health insurance is terrible? Please tell us all what coverage is on your child.
    Also, President Bush wants a tax credit for the poor to purchase HSA insurance in the free and open market. Plus, the President wants the Federal Government to make an HSA deposit as well. This way the poor will have first dollar coverage for themselves and their children. You should bone up on Republican healthcare reform.

  25. // HSAs don’t solve anything. //
    But they do look like a money-making tax shelter to the people who can afford them – and these are the ones who tend to think of themselves as representing the voice of the middle class and count as the middle class from the political point of view. That means HSAs could pull enough people away from health care reform enough to delay it for quite a while. Low income people will suffer in the meantime.
    //Uninsured going to the ER do get BILLED//
    In the case of Summit, the uninsured poor get billed after they are told they qualify for a charity program that will take care of “everything”.

  26. couple things.
    1. Providing $x of tax refunds for doctors who CHOOSE, out of the goodness of their hearts, to provide free care, is exactly as expensive as providing $x of medicaid or other government-sponsored care. BUT, Eric’s proposal doesn’t guarantee any fairness or balance to the system – it doesn’t guarantee that I can be seen and not charged – it doesn’t guarantee that everyone will be covered for the same type of care. It’s much more fair and efficient to spend the same amt of $ on govt coverage.
    2. Just because the ER has to SEE me doesn’t mean they won’t BILL me. Uninsured going to the ER do get BILLED, and in fact they get their WAGES taken. This is why health care is the #1 cause of personal bankruptcy. Eric’s solution does NOTHING to solve that. Yes, it compensated the Doctor – AFTER I go bankrupt after the collection agency goes after my wages.
    3. Commenters on this post have some uninformed ideas about HSAs. An HSA is a savings account of your OWN MONEY. You don’t “purchase” it. You put your own money into it. THen you spend it. It’s totally worthless for someone who can’t afford care in the first place. Oh yeah, it’s tax-free. Which is also useless for the poor. HSAs don’t solve anything.
    “HSA-eligible insurance plans” are real insurance, and if people are referring to those, then yeah it would be great if govt would help to pay for those, but they are all high deductible so you still have to help folks pay for that first $2,000 of care.

  27. Having spent another day at the County hospital (Highland Hospital) yesterday, I think patients should have a lost-income tax write off for income lost during the time they are waiting to be seen. Every time I’ve been there, it’s been a 6 hour endeavor, and that’s not including the hour of public transportation each way. And I was told I might have to go back. 🙁
    One of the reasons I’ve been against relying on physician benevolence (“incentives”) to provide care for the poor is now there are several layers of misdirection in the billing process that prevent the patient from directly dealing with the physician over the cost of his services. The physician isn’t going to get the patient calls to avoid them. The hospital bureacracy or the people who they’ve contracted to do billing are going to handle down-to-earth financial matters while physicians float around pretending to be caring and ethical.
    I found the way Highland handled billing yesterday really disturbing. The triage nurse didn’t give me any sense of whether my problem was serious or not. Thus, I didn’t have the necessary knowledge to elect *not* to move on to the next step (urgent care). Then I went to registration, discussed my financial situation, and agreed to take another trip back to the hospital so they can see if I fit into any government programs. No one showed me anything to show me how much the visit is going to cost if I don’t qualify for government programs. I contemplated cutting any potential losses by leaving at that point (and note all those Caring, Ethical Physicians were not around whether I left or not), but the triage nurse had referred me to urgent care, so there was a chance the situation might actually be urgent.
    Later, in Urgent Care, I asked a nurse if I had to change into a gown. She made a somewhat catty remark that I had to change into a gown because I had chosen to go to the ER, and if the problem wasn’t serious enough to warrant a gown, I would have gone to a “Corner Doc in a Box”. She clearly had no concept of the problems of the uninsured. If I had gone to a Doc in the Box, I would have been thrown out if I had indicated I was uninsured. (Or large guards would stand over me until I emptied my pockets, which happened to a friend of mine – and all she asked for was a payment plan).
    Why does the entire economy have to be market-based? The military seems to be based on concepts like honor and patriotism. When teachers engage in collective bargaining, they are told they have a “calling” not a job, and asking for market compensation Harms The Children. The Church is based on concepts of mission and pastoral care. There are many models for public service careers in our society. Health care is a public service, and it’s only society’s failure to facilitate the education of the necessary number of physicians that’s turning them into Rare, Costly Consultant-Experts.

  28. Eric, doctors are scamming the system now. I don’t think we want doctors not paying any income tax while all other Americans are being taxed through the nose.
    Trust me, under your proposal doctors would never pay taxes again. The New York Times is reporting that Medicaid costs $10,600 per person, per year. They are also reporting that 40% of the cost is fraud and abuse with the help of doctors. These costs are being paid by the American tax payers.
    Support Republican healthcare reform and a deduction for the purchase of individual HSA insurance.
    The AMA is running commercials on Rush radio saying call your Senators and have them raise Medicare payments to doctors. The AMA should get behind all Americans being able to deduct the cost of their HSA insurance premiums.
    Somebody somewhere should discuss Republican healthcare reform. Afterall, Republicans controll both Houses of Congress and the White House.
    President Bush says, “I urge you to find out how you can be empowered with a tax free HSA.”

  29. Rick- good pickup– it is usually not believed by those in the “hard goods” businesses that those of us in service industries cannot deduct losses for failure to pay for delivered services.
    However, on both the federal and state levels, tax concessions are made all the time for a variety of reasons– eg. farm subsidies, subsidies for moving businesses into very poor areas (economic empowerment zones).
    Simply put, this directly incentivizes (if that is a word) those who provide care, to provide care to those who can least afford it.
    In fact, a kind of proposal for this (albeit very limited) has been made in Florida:
    here is the link— http://www.orlandosentinel.com/news/local/volusia/orl-locvhealthzones13081305aug13,0,3896727,print.story?coll=orl-news-headlines-volusia

  30. I think Eric’s idea only thinks the problem halfway through. I don’t view doctors as businesses like the corner convenience store. I think they more accurately fit the mold of independent contractors, like the carpenter that remodels your kitchen. The doctor is certainly more highly educated, and carries greater responsibilities as required by his chosen profession, but when it comes to how he chooses where to work, and from where he receives income, he is much more like an independent contractor than a business. Business owners can hire, fire and supervise. Doctors cannot, unless they operate a private practice, in which case they are entitled to all the tax benefits of an independent business. To create such an opportunity for doctors now operating in the independent contractor mold would inevitably lead to legal claims of equitability from every other class of independent contractor who did work he didn’t get paid for — plumbers, health care consultants, etc.

  31. I like Eric’s ideas. If a surgeon owed $100,000 in Federal income taxes could he do just one surgery that costs $100,000 on someone who is uninsured and get out of all taxation?
    I like President Bush’s plan better. The President want’s a refundable tax credit for the poor to purchase the security of individual HSA health insurance in the free and open market. This way the citizen is insured and the insurance company will pay the surgeon and the surgeon can pay income taxes like the rest of Americans.

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