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Q: Aren't you just shifting costs to the poor?

"Aren't you just making poor people pay more? And what about those folks who can't pay? How are you going to make them pay?"

This was a question posed by a friend and nurse practitioner who I deeply respect. My answer is that you have to look at the plan in context.

First, only people in Adult P.S.Y.C.H. would be paying, and that's only after the other components are in place (Pediatric P.S.Y.C.H., Bridging P.S.Y.C.H., and Geriatric P.S.Y.C.H). Therefore, if you have a poor person who is intellectually disabled (formerly called mental retardation), they wouldn't have to pay. Or if they were chronic paranoid schizophrenic, or over 65 and in renal failure, they wouldn't have to pay because they would be covered under their respective plans.

So let's just discuss those folks who fall under the Adult P.S.Y.C.H. plan. Firstly, every adult has to pay something, and every adult needs to deal with the natural consequences of their actions. We know from our current consumer society that when people aren't aware of how much they are spending, they spend more. All Adult P.S.Y.C.H. does is:

  1. make people aware of how much money is in the pot;

  2. make people aware of how much things cost;

  3. require everyone to give into the pot in an amount commensurate with their income (or time);

  4. and give everyone a choice in provider and location.

For folks who can't pay, it's a case-by-case issue. A common scenario is an older, overweight man with poorly controlled type 2 diabetes who gets hospitalized. Once Adult P.S.Y.C.H. is in place, that man will automatically have yearly preventative visits covered, including lab work. As a result, he will be taught how to make good meal choices, how to dose his insulin, how to exercise, and he will be plugged into the right resources. He can still choose to have private insurance for which he must pay the entire premium.

So let's say that between his preventative visits, he is hospitalized for renal failure. He stays four days, and as a result, his bill is $2,000. (Remember, once we've established a price list, people will know up front how much things cost, within a narrow range.)

  • Possibility A: When reviewing his labs, the inpatient provider team will be able to compare his lab work to his outpatient lab work (because we'd have a universal medical record.) If the data shows his HbA1C (a maker of blood sugar over three months) is higher, that means he was noncompliant. As a result, when he leaves the hospital, he is responsible for paying his entire bill and no money will come from his state's general health care fund because his hospitalization is a direct result of his decisions. He can then work to find other philanthropic organizations that can help him pay the costs. For this possibility, the responsibility of being a good steward fell to the patient who did not do his part in keeping health care affordable.

  • Possibility B: When reviewing his labs, the inpatient provider team compared his lab work to his outpatient lab work and found that his HbA1C fell, along with his cholesterol and BMI. Hooray! As a result, when he leaves the hospital, he is responsible for paying a small portion of his bill (e.g. $500) with the general health care fund of his state paying for the other $1500. In this possibility, the patient was a good steward (because he made good subsequent choices), but his condition itself is largely non-genetic and preventable, thus he pays less but still must pay something to the system.

As for "making people pay," well our society has already established creatively sneaky ways to make people pay for all sorts of things. Since P.S.Y.C.H. wouldn't be usurping the ACA rule that "everyone has to have insurance", the government can still find ways to recoup the money. And remember, the finite amount of money in the general health care fund will be publicly known at any given time.

Keep the questions coming!

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