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Will All Health Care Reform Lead Back to Medicaid?

Jennifer Fisher Wilson
[+] Article, Author, and Disclosure Information

Potential Financial Conflicts of Interest: None disclosed.

Ann Intern Med. 2009;150(2):149-151. doi:10.7326/0003-4819-150-2-200901200-00024
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During the U.S. presidential campaign, the Republican and Democratic candidates proposed health care reform plans that emphasized reducing the number of uninsured Americans—approximately 45 million people younger than 65 years have no health care coverage. Their plans also focused on controlling health care costs, which consume 16% of the nation's gross domestic product, far more than that of any other developed country. The candidates promised to make health care reform a priority.

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Puerto Rico's Medicaid Woes
Posted on January 26, 2009
Rafael Juan Igartua
Conflict of Interest: None Declared

In theory, the Federal government provides 50%, and Puerto Rico provides 50% of the funds for Medicaid in Puerto Rico. However, the Federal government's contribution is capped at $300 million per year, unlike the states, which receive at least $2 billion per year. The cost of the Medicaid program in Puerto Rico far exceeds the Federal contribution. This forces Puerto Rico to provide 80% of the "wraparound" funds, versus the 50 states which only provide 20% of the funds.

Puerto Rico is behind in payments to health care clinics and several have sued in the U.S. District Court in San Juan to recover their payments. The four million American citizens who live in Puerto Rico pay Federal income taxes on sources of income outside of Puerto Rico (Section 933, U.S. Tax Code) and all employers and employees in Puerto Rico pay Social Security (FICA), Medicare, and Unemployment Security Taxes. The government of Puerto Rico alleged in court that this treatment [separate and unequal] violates the Uniformity Clause of the Constitution of the U.S. In a historic decision, the Hon. Federal Judge Gustavo Gelpi agreed, and is waiting for a reply from the U.S. Dept. of Justice.

This anomalous Medicaid situation in Puerto Rico has forced many families to move to the Continental U.S. to receive the care that they or their children need. In addition, health care providers in Puerto Rico are paid less by the Medicare Program for providing the same medical services available in the 50 states. This Medicare Program reimbursement disparity has promoted the exodus of hundreds of nurses, physicians and health care providers to the Continental U.S.

Puerto Rico's residents contributed nearly as much to the U.S. Treasury as the residents of North Dakota in 2007, this despite the fact that the per capita income in Puerto Rico is half that of the poorest state. I fully agree with Judge Gelpi that it is time for this [geographic] discrimination to end.


1. www.irs.gov...........Statistics of Income Tables for 2006 and 2007.

2. U.S. District Court San Juan: Playa de Ponce vs. Rullan, Civil No. 06-1260, 06-1524.

Conflict of Interest:

None declared

America's national health insurance: the demise of an incentive-based healthcare system
Posted on February 3, 2009
Shaheen E Lakhan
Global Neuroscience Intiative Foundation
Conflict of Interest: None Declared

A recent US national survey revealed that most physicians support government legislation to establish national health insurance (1). Not surprisingly, physicians in medical specialties showed the most support whereas procedure-based physicians (e.g. radiologists, anesthesiologists, and surgeons) demonstrated the least support. While the concept of national healthcare may be appealing in theory, if adopted the American public will undoubtedly be disappointed with the results. Can you remember the last time the general public was pleased with a government-sponsored program?

We as Americans are in love with the concept of fairness and equality. That notion of fairness extends to the concept of national healthcare. What we don't grasp is what national healthcare actually means from a practical point of view. If we look at any country with such a program in place such as in Canada or the UK, patients are limited by choice and must wait unacceptable lengths to see specialist physicians. Many of those populations are happy with their national healthcare system simply because they do not know better.

As a physician, have you ever tried to tell a patient that he or she cannot have the newer more cutting edge treatment because it is unaffordable? You will be met with fierce disappointment and opposition. Such are the demands of consumer driven medicine. We are a consumer-based society in America and there is no turning back.

A nationalized health plan is incongruent with consumer driven medicine. It is nothing more than a large HMO that is focused on costs rather than what is best for the patient. If you take the current Medicare system as an example, you will find that the reimbursements are so low that many physicians are opting-out and not participating with Medicare patients.

From a physician's point of view, a national healthcare system clearly means reimbursements will decline. Similar to other countries with nationalized health systems, physicians will flee to places where salaries are better. Similarly, the reason that industry sponsors so much research and development is for profits. Taking profit out of the system will cause those sponsors to leave for greener pastures. America as we know it will no longer be an innovator in healthcare advancement and technology.

While clearly access to care is important, it should not come at the cost of potentially destroying our incentive-based healthcare system as we know it.


1. Carroll AE, Ackermann RT: Support for National Health Insurance among U.S. Physicians: 5 years later. Ann Intern Med. 2008;148:566-567.

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