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By Robert Berry, MD Today marks the end of “Cover the Uninsured Week,” an eight-day media campaign spearheaded by the Robert Wood Johnson Foundation to endorse universal health care coverage for Americans. Today marks the end of “Cover the Uninsured Week,” an eight-day media campaign spearheaded by the Robert Wood Johnson Foundation to endorse universal health care coverage for Americans. The effort, backed by more than $80 million in active grants, aims at “ensuring that everyone in America has affordable and reliable health care coverage by 2010.” On the surface, it would seem unthinkable — even mean-spirited — to contest such a noble goal. Yet solving problems as difficult as 45 million uninsured Americans requires more than the grand pronouncements and glib panaceas promoted by the Cover the Uninsured Week campaign. They require action from those who have tough minds as well as tender hearts. It is health care — timely, competent, compassionate and cost effective — that Americans want. But the hard reality is that health care coverage does not equal health care. Universal coverage in Canada forces women to wait 14 weeks, on average, after they first bring a suspicious breast lump to a physician’s attention before it is removed. In Britain, universal coverage has caused a queue of more than 1 million awaiting elective surgery. Most Tennesseans know by now that our state’s decade-long experiment with Medicaid managed care is about to end coverage for many of those who are currently insured. Exactly one month after the kickoff of Cover the Uninsured Week, the TennCare program will begin the process of disenrolling more than 200,000 people. We as a state simply faced the hard reality that we cannot afford to cover 23 percent of our population and still pay for all the other items in Tennessee’s budget. As a primary care physician in Greeneville, Tenn., with roughly 3,500 uninsured patients in my practice, I attended the first public forum of Gov. Phil Bredesen’s task force on the health care safety net in early March. Because our clinic has provided something of a safety net since it opened in January 2001, I thought my contributions might prove useful. Unfortunately, the administration seems uninterested in ideas that don’t reinforce its own opinions. The major reason my clinic is more affordable than other primary care practices is that it doesn’t accept third-party payments and thus does not incur the cost of filing small medical claims. The clinic requires three fewer employees and costs about $200,000 less annually to operate than similar clinics that accept insurance to treat routine minor illnesses and injuries. Our fees, which patients pay at the time of service, typically are little more than the $32 that the governor’s consulting group, McKinsey & Co., recommended able-bodied TennCare recipients contribute as a co-payment for office visits. Given that our clinic has demonstrated the potential affordability and decreased costs of direct payment for routine medical care without using taxpayer money, one wonders if America needs or can even afford medical insurance for such services. It seems that the people who clamor most vociferously about covering the uninsured are usually the least likely to be found actually caring for them personally. Those who make their living from public coffers, either directly through subsidies or indirectly through tax exemptions, tend to resist citizen initiatives over which they have little control, even if citizens bear the costs themselves. In addition, government coercion through regulation can make it more difficult for physicians to solve the problems of their uninsured patients. For example, physicians must choose whether they will accept payments from Medicare, a program whose overhead costs make it impossible for a doctor to offer affordable rates in a true free market. The alternative is never to accept Medicare for any patient. Physicians who refuse to accept Medicare are also prevented from treating Medicare beneficiaries with an “urgent” condition — the definition of which is unclear and may be decided in court. With such hidden regulatory land mines, I recommend that physicians interested in starting practices like ours to serve all point-of-care payers (including the uninsured) turn Medicare beneficiaries away until legislators ensure a more physician-friendly regulatory environment. Increasingly, primary care physicians are coming to realize that they can escape bureaucratic hassles and costs and still make a decent living by not accepting insurance. Any campaign on behalf of the uninsured that does not address the regulatory issues impeding establishment of such clinics cannot really be concerned about either the uninsured who benefit from medical practices such as mine or the Medicare beneficiaries who, out of necessity, will be excluded from them.