What should we do about the Medicaid Gap?

Should we cobble together some new state program to close the “Medicaid Gap?” Should we take money from the taxpayers of Idaho to pay for the health care of the people of that population? I have a wild, radical idea. How about if instead of another government program, we promote a vibrant free market for health care in Idaho. That would make medical care affordable for the typical person, and even attract a great deal of patients from out of state to come here for care.

Now, you may be asking, what in the world is this crazy doctor talking about? Thanks for asking. As it turns out, I run just such a practice as I am describing. We just need more of them, spread around the state. Here is how it works. I do not take any insurance or Medicare or Medicaid. My overhead costs are low. I charge affordable fees. My patients pay me with money that they earn by providing services to others in their businesses. Instead of feeding at the taxpayer trough, my patients are out providing useful services to others, and being paid with those certificates of service that we call “dollars,” that they then give to me in exchange for my service. Everybody comes out ahead.

Now, when I say my care is affordable, here are some examples. Today, I saw a patient for a gout recurrence. I charged him $35 including his medication. This is the first attack in over a year, because I was previously very thorough in teaching him how to avoid gout attacks. I saw somebody else today who has a problem with triglycerides, and his fee was $64 including labs – there will not be a bill from the lab. I saw a man who previously had a heart attack, and he came to me again today because he quit taking his clot-reducing med plavix and his cholesterol-reducing med lipitor, and he ended up having a stroke while out of state. I supplied him 6 months of the lipitor for $48, which would have cost $180 at one of the big pharmacy chains that starts with a “W,” and 500 days of the plavix for $51, which would have cost him $500 at the aforementioned W. Those med costs included a fair markup for me. His visit, other than meds, was $106 including labs. An asthma follow-up was $19, and an ADD follow-up was $30. I did not cherry-pick these visits, those were the patients I saw this morning. As you can see, the typical working stiff has no trouble paying my fees. Today a patient left me a $12 tip.

Now, let us consider what the “Medicaid gap” really is. It is comprised of people who make too much money to force other people to pay for their health care through Medicaid, and make too little money to force other people to pay for their health care through Obamacare subsidies. Would it not be much better for these people to pay for their own care? If it is affordable, then they can. This so-called gap population is the majority of my patient base. These are the people that not only pay my fees, but often leave me tips.

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Well, you say, that is just fine and dandy for primary care, but what about surgeries? What about CT scans? There is a surgery center in Oklahoma that works much like I do. They are paid directly by their patients. I had an arthroscopic knee surgery with general anesthesia there three years ago, and the price was $3,740. That included everything – the surgeon, the anesthesiologist, and the hospital fee. Care was superb. They post their all-inclusive prices online. Inguinal hernia repair with mesh is still just $3,060. That costs less than two years of cigarettes for a pack per day smoker, which so many “poor” Americans are.

We are limited in what we can do to establish a medical free market in Idaho, because the central government has seized so much control over the health care marketplace. I am reluctant to call it a federal government, because the concept of federalism seems to have been destroyed. There are things we can do in Idaho, however. We can try to attract a surgical center to Boise that would function like the Surgery Center of Oklahoma. People would come from many states outside of Idaho to have their surgeries here. Dr. Keith Smith of the Surgery Center of Oklahoma has already helped set up similar facilities in Torrance, southern California, and one in Texas. Apparently he is not worried about the competition. He is doing quite a thriving business. So would a direct-pay surgery center in Idaho. The “gap” population would be able to afford surgeries. Business would be attracted to Idaho from Montana, Utah, Washington, Oregon, Wyoming, the Dakotas, and probably even further afield.

A radiology facility that worked the same way would attract patients from all over the region as well, to save people $2,000 on MRI scans and over $1,000 on CT scans. I know of no free market radiology facility in the United States. CT scans are available in Mexico at free market facilities, however. A patient of mine had one done in the Lake Chapala region for somewhere in the neighborhood of $100 – 150. There is no reason why an imaging center cannot be built in Idaho along these same lines.

We should work to encourage young doctors in their residencies in Boise, Coeur d’Alene, and Pocatello to remain in state and open medical practices like mine throughout the state. I would be willing to spend time with doctors who are interested in doing this, helping smooth the way to establishing their practices, giving talks at the residency programs, or having them shadow me in my practice. We should try to attract a free market imaging center, surgical center, and dental practices to the state. Idaho would become a medical tourist destination, and our “gap” problem would be solved, all without a tax-consuming state program. These are profitable business enterprises that need no propping up with outside funding.

Rather than expanding Medicaid, we should work on scaling it back. Health and Human Services now comprises the largest sector of total state spending in Idaho, according to If we could spend less on Medicaid, then perhaps taxes could be reduced. The more we establish free markets in Idaho, the more we should be able to cut back on Medicaid and ultimately on state taxes. Then the more we can cut state taxes, the more we would attract other businesses to Idaho.

Obamacare is clearly circling the drain. It seems likely that its failure was intentional, in order to revive the idea of the “public option.” Remember the chants? “All we want is the option!” Sure, the option to take other people’s money. If the varmints in Washington, D.C. can get their public option in place, then it will easily push out all private insurance, because it has taxpayer funding to keep it afloat. Then we will be left with the democrats’ goal all along — “single payer.”

Except that it will not really be single payer. Hundreds of thousands of people will also be payers. They will pay their own way out of pocket to get what they need in a reasonable time, and with good quality. This is what happens in countries with fully socialized medicine, like Canada and Great Britain. We will have a two-tier system like the English do, with agonizing waits and slipshod care in the government system, and high quality, thorough and prompt care in the free market system. People who can afford to do so will pay their own way. Those who suffer the most under socialized systems are those with the least money, who cannot afford to work around the system. Idaho can be well positioned in this America of the not-so-distant future, by doing all we can to establish free market practices now. They will benefit us immediately, and even more if Obamacare devolves into fully socialized medicine.

So do not close the Medicaid gap. Expand it! Develop a free market in medicine to the fullest extent possible, and help our economy, and therefore our people, to thrive.

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