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may a patient be transferred or after treatment, discharged. A separate issue is non-coverage
by insurance, in other words the huge population of patients who do not have insurance,
namely about 40 million before the financial crisis and passage of the Affordable Care Act
(ACA), otherwise known as Obama Care. ACA was projected by President Obama to cost
$900 billion over 10 years (the CBO in March 2010 estimated $940 billion) and cover most
uninsured Americans but now is projected by the CBO to cost $1.8 trillion over 10 years,
increase coverage by expanding Medicaid by 13 million people, and new government
insurance by 23 million, but with a loss of 7 million covered by employment based insurance.
There is however evidence that Medicare spending will decline from an expected annual cost
in 2020 of $1.050 trillion to $ 850 billion p.a. for a total cost of some $5.5 trillion over the
next seven years. The net gain is expected by CBO to be about 25 million additional covered
people from a projected high of 34 million in 2011. The issue at its simplest level is that
patients who wish to see a doctor or a nurse but do not immediately need urgent care must have
insurance to be treated. Historically those lacking insurance have found this care at a hospital.
The comparison is also complicated by the fact that in South Africa there are free clinics for
basic care run by charities and universities, often staffed by medical students under MD
supervision. In the USA this structure is much more difficult to setup because of medico legal
litigation and for example free care for Medicare patients is illegal. Having equivalent
outpatient clinics in the USA would alleviate some of the crowding problems at ERs that have
to take care of non-acute medical problems. However, a basic problem exists for long term
care, hypertension or diabetes for example, because the US system does not have effective
method of taking care of the indigent poor. Care of elderly patients in the US is virtually
unequalled by any other country as long as they take their medications, though in some studies
30% to 50% do not.
As for the comparison of quality of care, the NGO doctors at Shongwe were driven by a
passion for their work - a Raison de Etre - and a love for their patients that drove them to
exhaustion taking care of their patients, despite poor salaries, for a higher good and goal. They
did the best they could for their patients, irrespective of personal cost or danger. The same can
be said for the passion of many salaried physicians at many hospitals where I have worked in
the USA but, clearly it is not always the case. There is certainly a trend in newer generations
who have been trained under the restriction of not being allowed to work more than 80 hours a
week; once time is up its time to get out of the hospital. That mentality often continues on after
completion of training. The psychological affect has been a subtle change and positions that
allow working to a regular work schedule have become a more common trend. [According to
American Medical News, the number of hours physicians work has fallen by 5.9% from 57
hours, seeing 16.6% less patients. According to the Congressional Budget Office, 30 million
Americans will struggle to get physician access (not insurance coverage which will still be
about 10% of the population under ACA) and there will be a 139,000 physician shortfall by
2025. Of current physicians, 60% would retire if they could compared to 45% in 2008, and
more than 60% of physicians under the age of 40 years now are employed by hospitals,
physician groups, or other entities. Despite all of these statistics, the number of medical school
and residency slots has been kept constant for many years. Funding for residency training
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