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A Plan for the Uninsured in Texas

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Uninsured_Blog_Fleeger

I have a book that is very dear to me. It is not a rare book, nor a valuable book. 

But this book on World War II military campaigns means a lot to me because it was given to me by a patient. After many office visits we had learned of our mutual interest in history. My patient, knowing my father went to West Point, gave me the book as a token of his appreciation of my care. The relationship that all of us have with our patients is a special one, and I know my fellow physicians have similar stories that demonstrate the mutual respect inherent in the patient-physician relationship.

But, of course, there is more to this story. For my patient had been experiencing rectal bleeding for over nine months. He worked on a food truck selling snow cones, and was poor and uninsured. By the time he presented for medical evaluation he had metastatic disease. All I could do for him was give him a colostomy. My colleagues gave him chemotherapy to no avail. He ultimately passed from metastatic rectal cancer.

I’ve always wondered if my patient lived in a state with ACA expansion would he have been covered by Medicaid? Would he have had access to a primary care medical home? Would he have had access to a screening colonoscopy that could have prevented his disease? Would he at least have had access to early diagnosis and treatment with a greater chance of survival?

But we live in a state where that is not possible. We live in a state where 17.7% of Texans are uninsured. That’s 5 million Texans. That makes us 51st. That makes us last. We live in a state where 873,000 children – and growing – are uninsured. This represents 20% of all the uninsured children in the country.

I’m not telling you anything new. You – we – see this in our clinics, hospitals, and emergency departments every day. But as I’ve traveled around the state as your Texas Medical Association president, I’ve met many who feel the situation has reached a critical stage. It has become more difficult for Texas doctors to sustain this unwritten tax on ourselves, our clinics, and our hospitals as we care for the uninsured poor.

Yet our state seems to expect this from us.

Likewise, insured patients and employers and local property taxpayers are becoming increasingly more vocal about the cost shifting that occurs to pay for the care of uninsured patients.

And yet when we go to the Capitol, we tiptoe around this issue because we don’t want to offend the legislative majority.

It is the policy of our TMA that our patients have universal coverage.

It is the policy of our TMA that we draw down the tens of billions of dollars that Texas has passed up since the ACA became law a decade ago.

Yet, is it a TRUE goal of our TMA?

When we sit down with our legislators, do we ask them if they are going to use a waiver, or block grants, or expansion to help the uninsured? And exactly WHEN are they going to do that?

I understand the political realities. They are difficult.

We, as an association, can’t change this alone. We will need to build a coalition with county medical societies and specialty societies, along with hospitals, other health care professionals, patient advocacy groups, leaders in city and county government, the leaders of the major employers in Texas, and, yes, even the health plans.

I call for our TMA to bring all of these groups together to directly address the issue of the uninsured in Texas, to plan a strategy, and to put it in motion.

I believe we can, as an association and as a profession, create the change that our patients need and deserve.

I believe we can do so in a fiscally responsible manner.

I believe it is OK for legislators to feel the same discomfort I feel when I see an uninsured patient who can’t get good care in a timely manner because she is poor.

I know that if we stay true to our core values of uncompromising and unconflicted regard for our patients’ benefit and best interest that good things can and will happen … and I hope you believe the same.

(Dr. Fleeger’s made these comments at TMA’s 2020 Winter Conference on Jan. 25.)


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