Valley Voices

How to achieve a lasting, bipartisan solution to health care

The Fresno Bee

Speaking to the Electors of Bristol in 1774 on his election to Parliament, political philosopher Edmund Burke said an elected representative should ordinarily follow the wishes of his constituents, but not when they were against the representative’s judgment and conscience.

His actual words can be slightly modified to substitute “Congress” for “Parliament” and “Congressional District” or “state” for “Bristol.”

“Congress is not a congress of ambassadors from different and hostile interests; which interests must maintain, as an agent and advocate, against other agents and advocates; but Congress is a deliberative assembly of one nation, with one interest, that of the whole, where, not local purposes, not local prejudices, ought to guide, but the general good, resulting from the general reason of the whole.

“You choose a member, indeed; but when you have chosen him, he is not a member of a Congressional District/state, but he is a member of Congress.”

Burke added that “authoritative instructions; mandates issued, which the member is bound blindly and implicitly to obey, to vote, and to argue for, though contrary to the clearest conviction of his judgment and conscience…arise from a fundamental mistake of the whole order and tenor of our constitution.”

The upshot of Burke’s philosophy is that representatives are elected above all to lead, not just stubbornly to promote their district, state, camp, party, or campaign promises. The general good should be the guide.

In his Farewell Address, President Washington some 22 years later expressed a similar theme when he warned that the alternate domination of one elected “faction” over the other, animated by the spirit of revenge, risks chaos and the rise of a chief of some prevailing party who is given absolute power to stem the chaos, “on the ruins of public liberty.”

Health care personally affects everyone. The general good should be the guide. Leaders should recognize that major national health care legislation adopted on a bare majority vote over the strong objection of nearly half the country does not serve the general good.

When the bare majority flips again and throws out the latest legislation in four, six or eight years, the chaos Washington predicted looms. Obamacare, adopted on a bare majority, and the Republican House proposal, adopted on a bare majority, epitomize the concerns of Burke and Washington. A broader consensus, as was ultimately obtained for Medicare in 1965, is essential.

So how that consensus might be obtained? Federal and state law require that emergency rooms treat those who are unable to pay. Inadequate numbers of general practitioners and clinics result in far too many medically indigent people going to overcrowded ERs for care that should be provided at much less expense.

Grossly inadequate Medicaid payments for primary care doctors, and for specialists who receive referrals from them, are a main reason. The shortage leaves the ER as the only choice, and often for a much more serious and expensive problem that earlier primary or specialty care could have avoided. The government pays for emergency primary and serious care at measurable much greater cost.

No one likes five to 12-hour waits in the ER. This flawed system design should be corrected on a bipartisan basis, perhaps along the following lines:

▪  Repeal individual and employer mandates.

▪  Eliminate subsidies.

▪  Keep ban on pre-existing conditions exclusion.

▪  Keep dependent children coverage to age 26.

▪  Control insurer risk with limited enrollment period and premium adjustment factors.

▪  Control insurer risk with more aggressive government financing of primary care through high quality clinic expansion.

▪  Medical school loan relief and/or increased payment for clinic/primary care physicians.

▪  Medical school loan relief and/or increased payment for specialists linked to clinics.

▪  Clinic care at no charge for Medicaid eligible and sliding scale up to 400 percent of federal poverty level.

▪  Medicare/Medicaid continues outside of clinic system for freedom of choice.

▪  Innovative amendments to HIPAA.

▪  Greater flexibility for doctors to charge patients on retainer.

▪  Maintain employer health premium tax exemption and allow others a set deduction for health insurance premium.

Concerned citizens should speak up. Burke observed, “Nobody made a greater mistake than he who did nothing because he could only do a little.”

Daniel O. Jamison is an attorney and chair of the health law section at the law firm of Dowling Aaron Incorporated in Fresno. Connect with him at