Though the rollout of the Affordable Care Act (ACA) exchanges has dismayed even the law’s supporters, the problem the ACA is designed to address is real enough: Millions of Americans, even those with insurance, lack access to adequate healthcare. In a voluntary society, civil-sector groups would step up to provide social services, like healthcare for the needy.
Government intervention in health markets currently crowds out such services—but not completely. Remote Area Medical (RAM), a Tennessee-based charity that is completely privately funded, offers a glimpse of what voluntary healthcare might look like. The group treats all comers at free weekend clinics dotted across the country.
“Remote Area Medical provides stuff that no one else provides,” says Dr. David Milzman, a professor of emergency medicine at Georgetown University School of Medicine and emergency physician at MedStar Washington Hospital Center. “They can make 1,200 to 1,500 pairs of glasses a day. Talk about a life-changing thing: Doing an eye exam and then giving glasses to someone who’s never had glasses.”
Originally founded to do expeditions in South America, the group has shifted its focus homeward to address a need here. At a typical event, over a thousand patients arrive in the wee hours of the night to make sure they get a spot in line. Many drive for hours and sleep in their cars.
In addition to providing general medical care, RAM specializes in dental and vision work because diseases in these areas, although serious, can be permanently resolved in a few hours. Since 1992 RAM has organized over 700 events and seen over half a million patients in Tennessee, Illinois, California, Virginia, Texas, and other states.
But rather than welcome the organization, which operates at no cost to taxpayers, most state governments actively impede its efforts. In 2009, the Washington, D.C., Department of Health assessed it a $77,000 facilities fee and forced the group to apply for a certificate of need, which involves “proving” to a panel of bureaucrats that there is a need for services.
According to Milzman, who was part of an ad hoc group of doctors and nurses who tried to shepherd RAM through the approval process in D.C., the need for more services in the region is obvious. “They have beautiful dental facilities [for the poor] down at D.C. General,” says Milzman, “but no one to staff it. They have 15–16 operatories there, but they only staff it with one or two dentists a day. It’s crazy.”
Ultimately, D.C. officials refused to issue a one-time waiver to the district’s occupational licensing law, according to Milzman, who relates D.C. officials’ response as, “There is no medical problem in D.C. and we didn’t need a free clinic.” Milzman adds: “This was a disaster.”
Unfortunately, few states allow health workers licensed in other states to see patients—even when they are working for free. And the majority of RAM’s network of volunteers crosses state lines for events. “It’s a question of mathematics,” says RAM founder Stan Brock. More volunteers mean the group can see more patients.
According to Brock, occupational licensing laws are the biggest hurdle the group faces. Health officials cite safety concerns to justify barring out-of-state volunteers; for instance, how are California officials to know a nurse licensed in New Jersey is qualified?
But the objection rings hollow. All medical professionals must meet certification requirements administered by national specialty boards. Standards are thus nearly identical across states; the licenses themselves serve little purpose beyond raising revenue for state treasuries and keeping nurses’ salaries higher than they might be otherwise.
According to Brock, RAM has worked with over 80,000 volunteers without encountering an incompetent practitioner. Nonetheless, health officials regularly insist on licenses—even in emergencies. After a tornado demolished Joplin, Missouri, in 2011, RAM sent its mobile eyeglass clinic to help in the relief effort. But it had to turn around without making a single pair of glasses because they couldn’t find state-approved optometrists or opticians.
Medical malpractice liability is another stumbling block. The cost and complexity of insurance keeps many otherwise-willing practitioners from volunteering outside their regular practices. But efforts to ease liability rules face obstacles in state legislatures.
In Missouri this year, the state’s trial attorney association objected to a bill lifting liability except for cases of “willful misconduct.” Governor Jay Nixon vetoed the bill, which he mischaracterized as providing “blanket immunity” for volunteers. (Last month, legislators overrode the veto, prompting RAM to begin planning an event in St. Louis, its first in the state.)
But an absence of regulatory obstacles remains the exception, not the rule.
“The frequent comment that I get from would-be volunteers,” says Brock, “is that they throw up their hands and say, ‘Gosh, it’s easier for me to volunteer my time in Guatemala than it is in my own country.’”
Advocates for more government intervention often insist on referring to the pre-ACA status quo as the “free market.” RAM provides a useful corrective to that narrative. In a free market, would intransigent officials have so much power to stifle voluntary efforts to address one of the country’s most pressing problems?