Why must medical care be provided for free?

Our septic tank backed up recently. When I say backed up, I mean, into the basement. And when I say into the basement, I mean, out of the bathroom and onto the carpet. And under the walls. The stars were aligned, and I had to go to work. My wife borrowed a Shop-Vac and rented a steam cleaner. I was assigned to call the septic-tank guy. The kids helped clean up, and remain traumatized by revisiting their own body fluids … and solids.

Septic tank guy, who worked on our system a few years ago, said, “Oh, yeah, you’re that guy with all them children.” (This is the response I often get when people hear I have four, count ‘em, four children! The madness!) He informed me that we probably had overwhelmed our system and might need a new one. We were going on vacation, so it could sit until we returned.

Fast forward. The septic tank guy finally came, and found the problem after digging in our packed red clay with a backhoe. He was confident that I had never seen anything that disgusting. (I chuckled to myself. Real people can be far more disgusting than inanimate waste.)

The cost for locating and pumping the septic tank was $675. Hallelujah, no need for a new one! He came to the door, and handed me the bill. I told him thanks because he did a great job, and said I’d mail the check.

He paused, slightly flummoxed. “I can’t get paid now? Most people pay me right away. I mean, when can you pay me? I have to dump this, and it comes out of my pocket.”

I tried to explain that I could, indeed, write a check, but having just done my other bills, it would bounce. I’d need to move a little money around. “Well, I can work with you, but how long will it be?” asked my frustrated septic tank guy.

‘Look, I’ll send it to you tomorrow, but I just can’t hand it to you today. Do you understand?”

“Well, yeah, but I have expenses you know.”

At which point I launched into an explanation of how I see people all day who do not and likely will not ever pay me. I don’t think he bought it, but he went away, no doubt complaining that the doctor — the doctor of all people! — wouldn’t pay him when services were rendered. The horror!

This strikes at the crux of the problem facing physicians, whether working in EDs or on call for hospitals under EMTALA. Everyone (politicians, administrators, patients [AKA consumers], and customer advocates) is confident of a few things. First, emergency medical care is so important that no one should be expected to pay at the time of service or indeed ever “if they really need it.” “Emergency” means, in current parlance, everything from a painful tooth to sunburn, and of course, vastly worse things like lost prescriptions, heart attacks, trauma, and lack of confidence in a home pregnancy test.

Second, physicians are always wealthy, and have ready reserves to pay cash for everything. And third, nothing else is subjected to the immediacy of medical care. Let me interject here, a basement of sewage rises to a level of emergency far surpassing chronic back pain, poison ivy, possible insect bite, a prelitigation physical for whiplash, and other things that if listed would fill this publication.

Life is full of crises that are, believe it or not, nonmedical. If you are traveling with your children and your minivan gives up the ghost (Southern speak for dies) and you’re stuck in the middle of Iowa, you have a crisis. That crisis requires payment by credit card, insurance coverage, check, or cash.

If the roof blows off your house, you have a crisis. If your freezer or fridge stops working, if your electricity shuts off, if you have no water, you have a crisis. A house infested with fleas (and I speak from experience) is a crisis. These days, the way our economy and educational system uses Internet connectivity, having no Internet connection may even be a significant crisis.

Each and every one of these things, including food and water, requires payment unless you pack up the family, go off the grid, and set up your own compound. (I’ve considered it, believe me.)

So why must medical care be provided for free? Either via the cruel taskmaster of EMTALA or through universal health care? That is a reasonable question but one that no one in authority has the ability or honesty to address. Ethics, philosophy, and politics don’t mix.

More to the point, though, why is it that the government mandates that we provide care without immediate compensation but provides no voucher, no malpractice protection, no tax credit? This is a terrible double standard, and it needs to be brought to the desks of our legislators, county and state -medical societies, and national -organizations.

It creates an untenable economic situation, which partly explains the -closure of hospitals and EDs. This problem for practitioners lies behind the move of physicians from being owners to employees, the tendency of specialists to abandon on-call, and the desire of emergency physicians to leave clinical practice. Sometimes it’s burnout. Often these are explained by simple economics — and very reasonable frustration at the -asymmetry of the situation.

Medical practice and life is costly, but when the money doesn’t come in, it can’t go out. Anyone with a home, a family, and a practice will understand that this can’t continue. Herb Stein, Ben Stein’s economist father, said, “If -something cannot go on forever, it will stop.” The question is, what will America do when it suddenly has to pay for what has been free since 1986?

The plain truth is, as my septic tank friend said, “We have expenses.” At the end of the day, unlike our patients, we aren’t excused from paying.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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