Individually, many physicians willingly and unwillingly provide free care to many patients. When these patients come through the emergency room of the hospital the physicians are sometimes reimbursed at Medicaid rates (75% of the rates established by the governmant for Medicare) by the hospital for providing care to these uninsured and poor patients. The religious based hospitals in the Houston area have some compensation policies regarding the physician reimbursements, but the majority of the hospitals have no payment policy.

Since there is a very larger percentage of the population that have no insurance and can’t pay large medical bills when they come unexpectedly we have created a society in which the private employer thinks they are paying for the doctor’s and hospital’s bad debt through higher premiums, and the government thinks they are paying through the Medicare and Medicaid programs, and the doctors think they are just getting hammered for no good reason and the majority support a universal health plan like “Medicare for All Patients.” It is a peculiar system that looks very much like “taxation without representation” in that there are laws against refusing people emergency medical care but few laws about payment for the services. Is that not a form of taxation on a segment of the population that is licensed to deliver medical care?

In every generation of people before me the government has failed to address this problem. Today the government is attemting to address it through a requirment that the private system provider coverage to a greater portion of the population over that next several years. Still almost 30,000,000 people will be left out of that system because of their imigrant status or because of cost. It has never been that people could not get health care, though pride combined with a lack of charity has often interfered. It is a failure to provide a reasonable means to pay for that care that has put off any good solutions. I have no confidence that the situation will change even though in the current law some limited amount of thought has been given to reform of the health insurance system. The politics are still wrong and practical and universal reform is blocked. The true nature of the problem is not understood at all by the medical care providers nor by the money handlers. If it is understood well by Congress and the Executive Branch of government then they do not, in the majority, want reform that cost more than the current budget provides. They also do not want a public system in spite of the health problems and financial problems caused by the lack of such a system.

At this time, the solutions are outside of our system of government and outside of the economic models the leaders understand. It is very strange that the correction is actually in the hands of the people who suffer most from the problems, the patients. It is likely that the economic system that would address the problem is Parecon (participatory economics). I think, but I am not sure, that Parecon, in this case, would mean that patients would form and govern cooperatives through which they could hire or contract for appropriate medical services. Effectively, doing for themselves what they want government to do for them. The saying from Peter Maurin in his “Easy Essays” are now true, “that people in the past said of the Christians that they took care of themselves at a personal sacrifice , but now they pass the buck to the government.” Of course, Peter was living through the depression and helping feed people in soup kitchens in New York and did not see much positive in what governments had done in his lifetime. The difference in Peter and most of us in this time is that Peter did something everyday at a personal sacrifice about the problems he saw.

We have organized Medical Co-ops in which the uninsured and poor population can get care. It would not be so easy if the amount of money for primary medical care were not such a small percentage of the insurance dollar, less than 10%. That means that people who thought they could not have access to health care because they did not have health insurance can really afford to pay for primary health care using four hours of minimum wage labor per month. Even the folks with the signs who stand on the corners in our cities get enough money to “participate.”

Organizing these Medical Co-ops is not nearly as difficult as grass roots political organization. It is not contentious because it is based on the common needs of the members for better access to health care. Since no economist nor state nor federal government has yet addressed this access problem well enough to solve it for all of the citizens, no competing system has been created to limit the formation of community medical cooperatives. Such entities could become insurance companies as has happened in the past with farm cooperatives and fraternal organizations, but until they want to pool their money and buy health care services from multiple types of medical care providers, specialists and hospitals, then the complexity of insurance organization can be avoided. So, rather than become an insurance company, the cooperatives we have formed are a purchasing group for services that go beyond a simple payment agreement between their members and the primary care physician who takes care of them in the contracted medical co-op facilities.

About ten years ago physicians in many areas of the country started dropping out of insurance plans and offering their patients a monthly payment agreement for their medical services. The motives of the physicians seemed elitist as the reports were that they wanted patients to pay them substantial monthly fees for special attention and to also use their insurance, if they had that tacky stuff. The advertised rates were more than $100 per month or about five times as much as the Health Plans pay for primary care services. In my opinion, these offers were not particularly patient friendly and I have not seen any physicians in our area who have built their practices on this concept. However, the fact that an individual can pay a physician a monthly fee for medical services and that it not be part of the insurance system is empowering to both the patient and the physician. If you take out the greed and elitism, you can construct a system of care and payment that is the backbone of a medical cooperative.

An example of how we got started is as follows:

Members of TBT, a non-profit Christian organization in Houston incorporated a Non-Profit Association in 2005 called Senior Patient Association for the purpose of providing members with health care services. The Association is now called “Patient/Physician Cooperatives>” The sponsoring non-profit organization’s income producing work since 1995 has been the management of contracts between of physician groups and Health Plans, mostly Medicare Advantage Plans. As a consequence of that work the organization had very detailed information about the cost and quality of health in the Houston area and was able to create a Patient Association that is both economical and supported by many highly qualified physicians and nurses.

The Association (PPC) gives the medical cooperative proper governance and helps it recruit individual members. The Association began by getting pledges from enough families to have a group of 1500 individual members. They rented a clinic and staffed it with a physician and a nurse and volunteer administrators. After a year of demonstration that the cooperative would work, the association contracted with 33 physician offices to provider the primary care services through the Houston area.

The cost of primary health care services at the clinic was set at $26 per month per person on average These fees covered the cost of the physician, staff and overhead and no additional fees were charged for services at the clinic. Co-op membership was set at $15 per family per month and that amount covered administration and other member benefits such as dental and vision services throguh discount plans.

People who had Medicare and Medicaid could join a plan that contracted with the clinics and receive complete and comprehensive health care services including prescription drug coverage for no premium. Employers could also buy a plan that contracted with the clinics and had comprehensive health care services at a much reduced cost to the patient.

Individuals without Medicare, Medicaid, or employer sponsored Health Plans could join the clinic for primary health care services and use their health insurance to cover the specialty and hospital services that were required at other locations. They could also purcahse group health insurance throough the Association at 25% to 40% of the usual commercial rates.

The initial response from the mailer was 670 people in one month. That response was followed by another mailer and by meeting with those who made the pledges, so that in three months the first co-op was formed in 2009 and the clinic program was started. It has grown to 33 clinic locations in the Greater Houston Area.