An interesting article in this week's New England Journal of Medicine discusses the impact of the Affordable Care Act on illegal immigrants.  The author, who is at the University of North Carolina School of Medicine in Chapel Hill, says: 

In my practice in the teaching clinic of a family medicine residency program, I see many patients who are expected to benefit from the expansion of insurance access. Working-class people with costly chronic illnesses who do not qualify for Medicaid and have not reached the Medicare eligibility age will be ushered into the insurance pool and removed from our health care system's list of charity cases. In our practice, there is hope that it will become easier to serve patients who are currently uninsured.

I'm quite certain that the care of uninsured citizens is far from ideal, and that libraries of statistics show how their care is fragmented, wasteful, and substandard.    And yet the author sees them in his clinic...at least some of these people are getting some kind of care, and I'll bet the people seen in the author's clinic are expertly managed.  So are we talking about denial of care to the uninsured, or is it more of a question of who's paying?

With the full implementation of the ACA, tens of millions of Americans will receive access to routine health care services. This tidal wave of new patients will strain the health care infrastructure. If the claims of ACA proponents are true, the increased insurance access should all but eliminate uncompensated care and drastically reduce the need for charity care.

Does the author realize the contradictions in this paragraph?  Access to insurance is not the same as access to routine health care services.  At least some of the uninsured currently receive these services in the form of uncompensated and/or charity care.  Furthermore, access to insurance by no means guarantees access to health care services, if providers that are willing to see new patients are unavailable.  This is what is meant by "straining the health care infrastructure."

But what about illegal immigrants?

"...for the roughly 11 million undocumented persons living in the United States, the ACA is likely to make it more difficult to gain access to basic primary care services...Amid the current economic austerity and polarizing political climate, there are few who openly support the concept of public coverage of medical services for undocumented immigrants. Even President Barack Obama..."

I'll admit that personally I'm conflicted about this.  On one hand, I'm not happy that a waitress trying to raise two children has to help pay for a kidney transplant for someone who arrived here illegally.  On the other hand even in wartime, for goodness sake, doctors care for wounded enemy POW's. 

Fortunately, the author proposes a solution for this dilemma:

Could millions of people legally excluded from the insurance mandate prompt the emergence of new markets to meet their needs? Might providers respond by providing services according to how much patients are willing and able to pay, as in other sectors of the economy? Perhaps, over time, these market-oriented health care providers will control the cost of medical services in the same way that large retailers (such as Target and Wal-Mart) have by implementing $4 prescription formularies for generic drugs. It is not infeasible that the undocumented, who remain outside the purview of the new law, may attract the attention of care providers who yearn for a simpler, leaner practice that responds not to bureaucratic prescriptions but to patients' needs and values. Practice models that cater to the need for responsive, patient-centered care are likely to be both financially and professionally rewarding.

Truly, a brilliant idea:  a free market oriented approach to medical care that can be both cheaper and in every respect better than our present arrangement.  Undocumented immigrants would truly benefit from such a system.  Supplemented by a safety net of uncompensated and charity care for the truly impoverished, this just might have a chance of working.

I only wish that someone could devise a similar plan for the rest of us.