Socialized Medicine in America?

[Justin]

Interesting read... especially regarding the French and Canadian systems.

Sicko: Heavily Doctored, By Kurt Loder

Is Michael Moore's prescription worse than the disease?
By Kurt Loder

Michael Moore may see himself as working in the tradition of such crusading muckrakers of the last century as Lincoln Steffens, Ida Tarbell and Upton Sinclair — writers whose dedication to exposing corruption and social injustices played a part in sparking much-needed reforms. In his new movie, "Sicko," Moore focuses on the U.S. health-care industry — a juicy target — and he casts a shocking light on some of the people it's failed.

There's a man who mangled two of his fingers with a power saw and learned that it would cost $12,000 to save one of them, but $60,000 to save the other. He had no health insurance and could only scrape together enough money to salvage the $12,000 finger.

There's a woman whose husband was prescribed new drugs to combat his cancer, but couldn't get their insurance company to pay for them because the drugs were experimental. Her husband died.

Then there's a woman who made an emergency trip to a hospital for treatment and subsequently learned her insurance company wouldn't pay for the ambulance that took her there — because it hadn't been "pre-approved." And there's a middle-aged couple — a man, who suffered three heart attacks, and his wife, who developed cancer — who were bankrupted by the cost of co-payments and other expenses not covered by their insurance, and have now been forced to move into a cramped, dismal room in the home of a resentful son. There's also a 79-year-old man who has to continue working a menial job because Medicare won't cover the cost of all the medications he needs.

Moore does a real service in bringing these stories to light — some of them are horrifying, and then infuriating. One giant health-maintenance organization, Kaiser Permanente, is so persuasively lambasted in the movie that, on the basis of what we're told, we want to burst into the company's executive suites and make a mass citizen's arrest. This is the sort of thing good muckrakers are supposed to do.

Unfortunately, Moore is also a con man of a very brazen sort, and never more so than in this film. His cherry-picked facts, manipulative interviews (with lingering close-ups of distraught people breaking down in tears) and blithe assertions (how does he know 18 million people will die this year because they have no health insurance?) are so stacked that you can feel his whole argument sliding sideways as the picture unspools. The American health-care system is in urgent need of reform, no question. Some 47 million people are uninsured (although many are only temporarily so, being either in-between jobs or young enough not to feel a pressing need to buy health insurance). There are a number of proposals as to what might be done to correct this situation. Moore has no use for any of them, save one.

As a proud socialist, the director appears to feel that there are few problems in life that can't be solved by government regulation (that would be the same government that's already given us the U.S. Postal Service and the Department of Motor Vehicles). In the case of health care, though, Americans have never been keen on socialized medicine. In 1993, when one of Moore's heroes, Hillary Clinton (he actually blurts out the word "sexy!" in describing her in the movie), tried to create a government-controlled health care system, her failed attempt to do so helped deliver the U.S. Senate and House of Representatives into Republican control for the next dozen years. Moore still looks upon Clinton's plan as a grand idea, one that Americans, being not very bright, unwisely rejected. (He may be having second thoughts about Hillary herself, though: In the movie he heavily emphasizes the fact that, among politicians, she accepts the second-largest amount of political money from the health care industry.)

The problem with American health care, Moore argues, is that people are charged money to avail themselves of it. In other countries, like Canada, France and Britain, health systems are far superior — and they're free. He takes us to these countries to see a few clean, efficient hospitals, where treatment is quick and caring; and to meet a few doctors, who are delighted with their government-regulated salaries; and to listen to patients express their beaming happiness with a socialized health system. It sounds great. As one patient in a British hospital run by the country's National Health Service says, "No one pays. It's all on the NHS. It's not America."

That last statement is even truer than you'd know from watching "Sicko." In the case of Canada — which Moore, like many other political activists, holds up as a utopian ideal of benevolent health-care regulation — a very different picture is conveyed by a short 2005 documentary called "Dead Meat," by Stuart Browning and Blaine Greenberg. These two filmmakers talked to a number of Canadians of a kind that Moore's movie would have you believe don't exist:

A 52-year-old woman in Calgary recalls being in severe need of joint-replacement surgery after the cartilage in her knee wore out. She was put on a wait list and wound up waiting 16 months for the surgery. Her pain was so excruciating, she says, that she was prescribed large doses of Oxycontin, and soon became addicted. After finally getting her operation, she was put on another wait list — this time for drug rehab.

A man tells about his mother waiting two years for life-saving cancer surgery — and then twice having her surgical appointments canceled. She was still waiting when she died.

A man in critical need of neck surgery plays a voicemail message from a doctor he'd contacted: "As of today," she says, "it's a two-year wait-list to see me for an initial consultation." Later, when the man and his wife both needed hip-replacement surgery and grew exasperated after spending two years on a waiting list, they finally mortgaged their home and flew to Belgium to have the operations done there, with no more waiting.

Rick Baker, the owner of a Toronto company called Timely Medical Alternatives, specializes in transporting Canadians who don't want to wait for medical care to Buffalo, New York, two hours away, where they won't have to. Baker's business is apparently thriving.

And Dr. Brian Day, now the president of the Canadian Medical Association, muses about the bizarre distortions created by a law that prohibits Canadians from paying for even urgently-needed medical treatments, or from obtaining private health insurance. "It's legal to buy health insurance for your pets," Day says, "but illegal to buy health insurance for yourself." (Even more pointedly, Day was quoted in the Wall Street Journal this week as saying, "This is a country in which dogs can get a hip replacement in under a week and in which humans can wait two to three years.")

Actually, this aspect of the Canadian health-care system is changing. In 2005, the Canadian Supreme Court ruled in favor of a man who had filed suit in Quebec over being kept on an interminable waiting list for treatment. In striking down the government health care monopoly in that province, Chief Justice Beverley McLachlin said, "Access to a waiting list is not access to health care." Now a similar suit has been filed in Ontario.

What's the problem with government health systems? Moore's movie doesn't ask that question, although it does unintentionally provide an answer. When governments attempt to regulate the balance between a limited supply of health care and an unlimited demand for it they're inevitably forced to ration treatment. This is certainly the situation in Britain. Writing in the Chicago Tribune this week, Helen Evans, a 20-year veteran of the country's National Health Service and now the director of a London-based group called Nurses for Reform, said that nearly 1 million Britons are currently on waiting lists for medical care — and another 200,000 are waiting to get on waiting lists. Evans also says the NHS cancels about 100,000 operations each year because of shortages of various sorts. Last March, the BBC reported on the results of a Healthcare Commission poll of 128,000 NHS workers: two thirds of them said they "would not be happy" to be patients in their own hospitals. James Christopher, the film critic of the Times of London, thinks he knows why. After marveling at Moore's rosy view of the British health care system in "Sicko," Christopher wrote, "What he hasn't done is lie in a corridor all night at the Royal Free [Hospital] watching his severed toe disintegrate in a plastic cup of melted ice. I have." Last month, the Associated Press reported that Gordon Brown — just installed this week as Britain's new prime minister — had promised to inaugurate "sweeping domestic reforms" to, among other things, "improve health care."

Moore's most ardent enthusiasm is reserved for the French health care system, which he portrays as the crowning glory of a Gallic lifestyle far superior to our own. The French! They work only 35 hours a week, by law. They get at least five weeks' vacation every year. Their health care is free, and they can take an unlimited number of sick days. It is here that Moore shoots himself in the foot. He introduces us to a young man who's reached the end of three months of paid sick leave and is asked by his doctor if he's finally ready to return to work. No, not yet, he says. So the doctor gives him another three months of paid leave — and the young man immediately decamps for the South of France, where we see him lounging on the sunny Riviera, chatting up babes and generally enjoying what would be for most people a very expensive vacation. Moore apparently expects us to witness this dumbfounding spectacle and ask why we can't have such a great health care system, too. I think a more common response would be, how can any country afford such economic insanity?

As it turns out, France can't. In 2004, French Health Minister Philippe Douste-Blazy told a government commission, "Our health system has gone mad. Profound reforms are urgent." Agence France-Presse recently reported that the French health-care system is running a deficit of $2.7 billion. And in the French presidential election in May, voters in surprising numbers rejected the Socialist candidate, Ségolène Royal, who had promised actually to raise some health benefits, and elected instead the center-right politician Nicolas Sarkozy, who, according to Agence France-Presse again, "plans to move fast to overhaul the economy, with the deficit-ridden health care system a primary target." Possibly Sarkozy should first consult with Michael Moore. After all, the tax-stoked French health care system may be expensive, but at least it's "free."

Having driven his bring-on-government-health care argument into a ditch outside of Paris, Moore next pilots it right off a cliff and into the Caribbean on the final stop on his tour: Cuba. Here it must also be said that the director performs a valuable service. He rounds up a group of 9/11 rescue workers — firefighters and selfless volunteers — who risked their lives and ruined their health in the aftermath of the New York terrorist attacks. These people — there's no other way of putting it — have been screwed, mainly by the politicians who were at such photo-op pains to praise them at the time. (This makes Moore's faith in government medical compassion seem all the more inexplicable.) These people's lives have been devastated — wracked by chronic illnesses, some can no longer hold down jobs and none can afford to buy the various expensive medicines they need. Moore does them an admirable service by bringing their plight before a large audience.

However, there's never a moment when we doubt that he's also using these people as props in his film, and as talking points in his agenda. Renting some boats, he leads them all off to Cuba. Upon arrival they stop briefly outside the American military enclave on Guantanamo Bay so that Moore can have himself filmed begging, through a bullhorn, for some of the free, top-notch medical care that's currently being lavished on the detainees there. Having no luck, he then moves on to Cuba proper.

Fidel Castro's island dictatorship, now in its 40th year of being listed as a human-rights violator by Amnesty International, is here depicted as a balmy paradise not unlike the Iraq of Saddam Hussein that Moore showed us in his earlier film, "Fahrenheit 9/11." He and his charges make their way — their pre-arranged way, if it need be said — to a state-of-the-art hospital where they receive a picturesquely warm welcome. In a voiceover, Moore, shown beaming at his little band of visitors, says he told the Cuban doctors to "give them the same care they'd give Cuban citizens." Then he adds, dramatically: "And they did."

If Moore really believes this, he may be a greater fool than even his most feverish detractors claim him to be. Nevertheless, medical care is provided to the visiting Americans, and it is indeed excellent. Cuba is in fact the site of some world-class medical facilities (surprising in a country that, as Ricardo Alonso-Zaldivar noted in the Los Angeles Times last month, "imprisoned a doctor in the late 1990s for speaking out against government failure to respond to an epidemic of a mosquito-borne virus"). What Moore doesn't mention is the flourishing Cuban industry of "health tourism" — a system in which foreigners (including self-admitted multimillionaire film directors and, of course, government bigwigs) who are willing to pay cash for anything from brain-surgery to dental work can purchase a level of treatment that's unavailable to the majority of Cubans with no hard currency at their disposal. The Cuban American National Foundation (admittedly a group with no love for the Castro regime) calls this "medical apartheid." And in a 2004 article in Canada's National Post, writer Isabel Vincent quoted a dissident Cuban neurosurgeon, Doctor Hilda Molina, as saying, "Cubans should be treated the same as foreigners. Cubans have less rights in their own country than foreigners who visit here."

As the Caribbean sun sank down on Moore's breathtakingly meretricious movie, I couldn't help recalling that when Fidel Castro became gravely ill last year, he didn't put himself in the hands of a Cuban surgeon. No. Instead, he had a specialist flown in — from Spain.

[Harrison]

Interesting take on the current system(s). It’s funny – after speaking with U.S. patients, it seems like most of us simply want the private insurance companies to pay up – rather than moving towards socialized medicine!?

Perhaps a poll will be interesting….

[Justin]

Analysis: 'Sicko' numbers mostly accurate; more context needed

http://www.cnn.com/2007/HEALTH/06/28...eck/index.html

Story Highlights Analysis: Numbers cited in "Sicko" are accurate for the most part Assertions could use more context to flesh out comparisons of health care Health-care experts focus more on film's errors of omission than incorrect facts

By A. Chris Gajilan
CNN

(CNN) -- Michael Moore's "Sicko," which opened nationwide Friday, is filled with horror stories of people who are deprived of medical service because they can't afford it or haven't been able to navigate the murky waters of managed care in the United States.

It compares American health care with the universal coverage systems in Canada, France, the United Kingdom and Cuba.

Moore covers a lot of ground. Our team investigated some of the claims put forth in his film. We found that his numbers were mostly right, but his arguments could use a little more context. As we dug deep to uncover the numbers, we found surprisingly few inaccuracies in the film. In fact, most pundits or health-care experts we spoke to spent more time on errors of omission rather than disputing the actual claims in the film.

Whether it's dollars spent, group coverage or Medicaid income cutoffs, health care goes hand in hand with numbers. Moore opens his film by giving these statistics, "Fifty million uninsured Americans ... 18,000 people die because they are uninsured."

For the most part, that's true. The latest numbers from the Centers for Disease Control and Prevention say 43.6 million, or about 15 percent of Americans, were uninsured in 2006. For the past five years, the overall count has fluctuated between 41 million and 44 million people. According to the Institute of Medicine, 18,000 people do die each year mainly because they are less likely to receive screening and preventive care for chronic diseases.

Moore says that the U.S. spends more of its gross domestic product on health care than any other country.

Again, that's true. The United States spends more than 15 percent of its GDP on health care -- no other nation even comes close to that number. France spends about 11 percent, and Canadians spend 10 percent.

Like Moore, we also found that more money does not equal better care. Both the French and Canadian systems rank in the Top 10 of the world's best health-care systems, according to the World Health Organization. The United States comes in at No. 37. The rankings are based on general health of the population, access, patient satisfaction and how the care's paid for.

So, if Americans are paying so much and they're not getting as good or as much care, where is all the money going? "Overhead for most private health insurance plans range between 10 percent to 30 percent," says Deloitte health-care analyst Paul Keckley. Overhead includes profit and administrative costs.

"Compare that to Medicare, which only has an overhead rate of 1 percent. Medicare is an extremely efficient health-care delivery system," says Mark Meaney, a health-care ethicist for the National Institute for Patient Rights.

Moore spends about half his film detailing the wonders and the benefits of the government-funded universal health-care systems in Canada, France, Cuba and the United Kingdom. He shows calm, content people in waiting rooms and people getting care in hospitals hassle free. People laugh and smile as he asks about billing departments and cost of stay.

Not surprisingly, it's not that simple. In most other countries, there are quotas and planned waiting times. Everyone does have access to basic levels of care. That care plan is formulated by teams of government physicians and officials who determine what's to be included in the universal basic coverage and how a specific condition is treated. If you want treatment outside of that standard plan, then you have to pay for it yourself.

"In most developed health systems in the world, 15 percent to 20 percent of the population buys medical services outside of the system of care run by the government. They do it through supplemental insurance, or they buy services out of pocket," Keckley says.

The people who pay more tend to be in the upper income or have special, more complicated conditions.

Moore focuses on the private insurance companies and makes no mention of the U.S. government-funded health-care systems such as Medicare, Medicaid, the State Children's Health Insurance Program and the Veterans Affairs health-care systems. About 50 percent of all health-care dollars spent in the United States flows through these government systems.

"Sicko" also ignores a handful of good things about the American system. Believe it or not, the United States does rank highest in the patient satisfaction category. Americans do have shorter wait times than everyone but Germans when it comes to nonemergency elective surgery such as hip replacements, cataract removal or knee repair.

That's no surprise given the number of U.S. specialists. In U.S. medical schools, students training to become primary-care physicians have dwindled to 10 percent. The overwhelming majority choose far more profitable specialties in the medical field. In other countries, more than one out of three aspiring doctors chooses primary care in part because there's less of an income gap with specialists. In those nations, becoming a specialist means making 30 percent more than a primary-care physician. In the United States, the gap is around 300 percent, according to Keckley.

As Americans continue to spend $2 trillion a year on health care, everyone agrees on one point: Things need to change, and it will take more than a movie to figure out how to get there.

A. Chris Gajilan is a senior producer with CNN Medical News. Intern Emily Breidbart contributed to this report.

[ZorroSF]

If you've seen the movie he displays a list of countries as a ranking and the US received number 27 or something like that.

However, if you look below the US on that list, I believe two slots below, is Cuba. In an interview on DemocracyNow.org he gave the reason why he used Cuba as an example to disparage our healthcare system. In the late 90's he had a TV show called the Aweful Truth. One of the episodes he tested the american healthcare system agains the Canadien and Cuban healthcare systems.

He rated Cuba as number one simply because they were the most efficient. Not because they were the best at anything. I believe Canada did better quality, but Cuba was the fastest. Still, the US came in dead last.

[Harrison]

Believe it or not, the United States does rank highest in the patient satisfaction category.

Well, this is quite interesting. It's amazing that they managed to implement a scientifically rigorous poll to arrive at this crazy conclusion! Chris, Emily?! Wuddupwiddat?! How about some sources?

Zorro, good points about efficiency. So maybe we are getting closer to unfairly branding each country's medical system:

Cuba - efficiency
Canada - quality
US - profit (for HMOs)

Joking aside, this is a very serious issue that is and will continue to affect us all. Gosh, if we can only make a little difference, it may save a life!

Justin, how do you feel about all this, given your thoughtful posts?

[LBP]

I of course have a few comments.

In a recent interview...cant recall which night news show...Moore defended his portrayal of Cuba's systems as follows...one of the 911 people who was treated in front of Moore's camera's, later snuck into a facility and represented herself as a Cuban...and states she was given the exact same treatment with and without the cameras, as a Cuban and as an American.

Next: Moore's movie isn't expected to provide all the answers...but it is expected and intended to open a DIALOUGE about what needs to be fixed and to open our eyes to the possibility of other systems in other countries.

Finally a personal perspective of the auto insurance industry...and I think its safe to assume it's not much different in the health care setting.


For a short time during my legal career, I defended companies and their insurers in automobile personal injury accident cases. One of the insurers we worked with was a huge company I cannot name. They have a ton of people insured with them, and for a defense law firm...it's a solid base of billable hours. However, this unnamed insurance company low balls what it's willing to pay attorneys to do the work in defending them. We often spent hours extra on each case that we were not allowed to bill for and even after that they take another 10% or more off the bill.

Then...they would never pay any claims to the insureds...denying, stalling and low balling any pay outs.

But on the flip side...I had a friend who's husband was a hedge fund investor and his hedge fund company's only client was the same insurance company I was working to defend. I was living paycheck to paycheck barely paying rent, and law school loans, no vacations, not a lot of spending money, and credit card debt on the rise....while my friend's husband's partners left other hedge fund groups to work for this insurer...and I can't fathom their income because all I heard was the hedge fund group they walked away from -for this opportunity- offered millions in bonuses at the end of the year!

It's just disgusting that the people who pay premiums for auto insurance don't get paid on claims when they are injured, and the attorneys who are defending them, trying to minimize their costs, get lowballed for their services, but the few people who play with there money to make them more money...get rewarded obscene amounts of bonuses! It's just repulsive when you realize the vast differences of our profit driven society.

Now if I had been working to defend my health insurer in some bad faith claim, while being denied my surgery and hearing about a friend who was making millions off of investing my monthly premiums I'd go insane...and I know it's happening...That's whats wrong with America.

[Justin]

Bottom line: insurance companies are EVIL--screwing patients and physicians alike--and open dialogue on this issue is only a good thing.

1. Patients get screwed by insurance companies.
2. Physicians get screwed by insurance companies.

Unfortunately, I don't see any change in #1,2 in the near future. It is insane that care is dictated by some insurance bean counter that doesn't understand an ounce of the medical world... that's the American way.

Physicians are held hostage by insurance companies.

A quote from Robert DeGroote MD, FACS, that sums things up nicely:

"As a practicing general and vascular surgeon for the last 20 years, I watched the development of a sad scenario that I never thought possible: A once proud, respected, trustworthy, and noble profession brought to its knees by those not trained in the honorable art and science of medicine and whose only motive is profit."

Justin

[Ouch!]

Justin,

You hit the nail on the head. We are all hostages of the insurance company. I worked in a hospital about 30 years ago; at that time it was the doctors who dictated what care a patient recieved. If the doctor said certain tests were needed, they were done. It was the doctor who determined how long a patient stayed in the hospital, and he determined that based on the patient's condition. Insurance would pay for these things.

Now an insurance chart & codes determine what procedures are paid for & how long you can stay in the hospital for a certain procedure regardless of the patient's condition.

I have talked with friends in other countries and their systems have increasing problems too.

I believe we all think the health care insurance coverage issue needs work. But I am not sure how we fix this insurance problem.

Jane

[chasswen]

well first off it would mean the world if all insured were treated = as they need to pay for fda approved devices etc... upon there approval. that would solve most of the issues.
with insurance companies being able to pick and choose what they will cover is bull crap.
and for any people not insured by the feds then and fda means nothing. now thats the major problem in my mind.
chuck

[Harrison]

Sad news about the “Mass Miracle” in “Universal Health Care.” I think many informed readers saw this coming a mile away. It’s quite unfortunate that the insurance companies win – while doctors are overworked and patients suffer from increasingly fewer medical options!

http://online.wsj.com/public/article...004277031.html (Subs. Required for full article, text below).

Doctor Shortage Hurts
A Coverage-for-All Plan
By ZACHARY M. SEWARD
July 25, 2007; Page B1

BOSTON -- Tamar Lewis runs a makeshift hair salon out of her one-bedroom apartment in Roxbury, a low-income neighborhood here. She's 24 years old and has been cutting hair since she dropped out of high school in 2002. Until recently, she never had health insurance.

"Good thing I never snipped one of these off," Ms. Lewis jokes, wiggling 10 fingers. Earlier this month, she signed up for state-subsidized insurance under a new Massachusetts law that aspires to universal coverage. The plan costs her $80 a month.

But it takes a lot more than an insurance card to see a doctor in this state. On the day Ms. Lewis signed up, she said she called more than two dozen primary-care doctors approved by her insurer looking for a checkup. All of them turned her away.

Her experience stands to be common among the 550,000 people whom Massachusetts hopes to rescue from the ranks of the uninsured. They will be seeking care in a state with a "critical shortage" of primary-care physicians, according to a study by the Massachusetts Medical Society released yesterday, which found that 49% of internists aren't accepting new patients. Boston's top three teaching hospitals say that 95% of their 270 doctors in general practice have halted enrollment.
For those residents who can get an appointment with their primary-care doctor, the average wait is more than seven weeks, according to the medical society, a 57% leap from last year's survey.

The dearth of primary-care providers threatens to undermine the Massachusetts health-care initiative, which passed amid much fanfare last year. Newly insured patients are expected to avail themselves of primary care because the insurance covers it. And with the primary-care system already straining, some providers say they have no idea how they will accommodate an additional half-million patients seeking checkups and other routine care.

"Health reform won't mean anything for the state's poor if they can't get a doctor's appointment," says Elmer Freeman, director of the Center for Community Health, Education, Research and Service in Boston. And even though people with subsidized insurance, like Ms. Lewis, can consult specialists within the plan's network without prior authorization from a primary-care doctor, they need such approval to visit a specialist who isn't in the network.
State officials have acknowledged the problem. "Health-care coverage without access is meaningless," Gov. Deval Patrick said in March.

As it happens, primary-care doctors, including internists, family physicians, and pediatricians, are in short supply across the country. Their numbers dropped 6% relative to the general population from 2001 to 2005, according to the Center for Studying Health System Change in Washington. The proportion of third-year internal medicine residents choosing to practice primary care fell to 20% in 2005, from 54% in 1998.

A principal reason: too little money for too much work. Median income for primary-care doctors was $162,000 in 2004, the lowest of any physician type, according to a study by the Medical Group Management Association in Englewood, Colo. Specialists earned a median of $297,000, with cardiologists and radiologists exceeding $400,000.

At the same time, the workweek for primary-care doctors has lengthened, and they are seeing more patients. The advent of managed care in the mid-1990s added to the burden as insurance companies called on primary-care doctors to serve as gatekeepers for their patients' referrals to specialty medicine.

In Massachusetts, the state-subsidized plans, collectively called Commonwealth Care, are provided by private insurance companies. Patients can choose from among six options. Residents who make between one and three times the poverty level ($48,000 for a family of three) are now eligible for coverage under the plan. Doctors are reimbursed by insurance providers -- at below-market rates comparable with Medicaid reimbursements.

The doctor-shortage problem in Massachusetts is especially acute at community health centers, which are likely to face the largest influx of newly insured patients. A product of Lyndon Johnson's antipoverty initiatives of the 1960s, health centers accept any patient, regardless of ability to pay. Seventy percent of their patients nationwide live below the poverty line.
In the Jamaica Plain neighborhood of Boston, all three community health centers have placed a temporary freeze on primary-care enrollment because they don't have enough doctors. Dorchester House, a community health center in southeast Boston, had nearly 55,000 primary-care visits last year to its 21 doctors and nurse practitioners.

"We've barely got room to treat anyone else," says Patrick Egan, the center's medical director. "We're pushing it already."

Nationwide, 13% of family-medicine positions are unfilled at federally financed health centers, according to a study published last year in the journal JAMA. One internal-medicine vacancy at Dorchester House has gone unfilled for the past three years.

Under the Massachusetts initiative, residents who don't get covered will pay a penalty on their state taxes, and companies with more than 10 employees will face a fine for each worker to whom they don't provide insurance. The law officially took effect on July 1, but the state won't impose any penalties until next year.

Ms. Lewis signed up for Commonwealth Care on July 3. Her search for a primary-care doctor has been instructive. "I thought insurance was supposed to be some kind of great thing, but it hasn't changed" anything, she says. Pointing down the block at the Whittier Street Health Center in Roxbury, she says, "I guess that's where I'll go."