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Interviews
Jay Moreland, M.D.
Stephen D. Ratcliffe Community Health Center
Interviewer
You work for a Community Health Center, how is that different from other clinics?
Jay Moreland
Community Health Center is a national program that supports clinics that take care of patients in under-served areas, so there can be community health centers in the inner city, or out in the rural areas, and the federal government has certain criteria for what qualifies for an under-served area based on the number of doctors per a certain amount of patients. And then they provide financial assistance to those clinics. And in order to qualify for that you have to be open to patients who are uninsured or under-insured, so in order for us to continue qualifying for community health center status, the majority of our board has to be our patients. So my bosses are actually my patients, that's #1.
Number two we have to have a sliding fee scale so basically so poor people who can't afford what it really costs to see a doctor can pay based on sliding fee scale based on their income and the size of their family. So we do means testing meaning we figure out whether they qualify for a sliding fee scale. We also see insured patients as well. And there's some other qualifications that may change from congressional session to year to year. But basically those are the criteria. And in return the federal government gives a certain amount of money depending on the size of the clinic in your area to support the operations, and in addition they help support us by supporting us with our malpractice insurance, because if we had the large burden of the uninsured and had to pay malpractice insurance as well you just couldn't survive as a business, so that's one of the benefits. Then they have a lot of other benefits that we can bring in for our patients within the community health system that help us take care of the patients, for example, prescription drug pricing at local pharmacies that are at a discount and certain other kinds of programs and support systems that help us do what we need to do to take care of the patients. For example, there is the Americorp Program, which is a separate federal program, but a lot of those people from the Americorp Program come to community health centers and they do their service there to help out that situation as well.
Interviewer
What is the mission of the clinic?
Jay Moreland
The mission is to provide quality healthcare to patients, regardless of their ability to pay, and no matter what their age group or ethnicity.
Interviewer
Sounds like you have a cooperative network with hospitals and other agencies around town. How does that work?
Jay Moreland
Well it's very individual depending on which community health center system you happen to be in and there are some community health centers, for example in Colorado, where they have a large amount of help from the states, from the local hospitals and others that maybe have less, so for example, in our particular system we get a significant amount of funds from Intermountain Healthcare to help support our mission, and we also get certain services provided at a discount at certain other IHC hospitals or IHC hospitals where we can have, for example, x-rays that are done at a discount rate--so that's one particular way. Then in the Utah area we have the HAP program which is the Health Access Project, and it's basically doctors from whatever specialty who volunteer to do a certain amount of care for patients without regard for their ability to pay, and there's a certain amount of funding that comes for that that helps to support some of those services, our community health centers actually are the administrators of that program. So we not only do that for our patients, but we do that for patients throughout, for example, the Salt Lake valley to get them in to see a specialist for whatever is available for that particular specialty. And then a variety of as-needed negotiations with the hospitals in terms of donated services on an individual patient basis. Basically when we see a need in our patient population, we try to negotiate with whoever seems most likely to be able to provide that service, and we have support also from the United Way, for example, to help us get things done. The Utah Cancer Control program is also another program that we utilize that helps gets pap smears and mammograms and things like that, so it's a bit of a hodgepodge, but we do whatever we can to try to do as much as we can.
Interviewer
It seems like you treat more than the physical needs of your patients. Is that a philosophy that you have?
Jay Moreland
It's certainly part and parcel of what doctors are supposed to do. When you go to medical school and what they talk about. They say... you know you treat the whole person and you really have to take into account their family, their social context, their resources. They teach that to you in medical school as something you're supposed to do. And certainly in the specialty family practice that's supposed to be part and parcel of how we take care of patients, so it's certainly what I was raised to do and I try to do.
Interviewer
There must be frustrations because of physical and financial limitations. What are some of your frustrations you run into in your daily practice?
Jay Moreland
The number one frustration is financial--there aren't resources to do what needs to be done. There's a resident physician who did a study in our clinics a couple of years ago that determined that the main reason why people don't take their medicines is because they can't afford them, and then there are consequences because of that, you know worsening diabetes or heart attacks and things like that. And really there is a lot of limitation of what I can do based on people's difficulty with doing something that costs money. And in my patient population, more than 50% of my patients are uninsured, and then on top of that mostly impoverished--you know really not making much money, and when you have a choice between paying the rent and paying for a medicine it means that you and your family could get kicked out of your apartment if you don't pay the rent versus not paying for your medicine. Well it's sort of an obvious choice there. Or if your kids need to be fed and you have a choice between feeding your kids and buying this medicine, you know sometimes that's reality--that's the cold-hearted reality of poverty. So, there's a lot of other frustrations as well, I mean there's sort of a... the way our health care system is set up right now is basically set up to be, for the most part, a two-tiered system, and it works great for the upper tier, but for the lower tier it doesn't work so well. Actually I would say that people think that it works well for the upper tier as well, but what they don't realize is it's not working so hot for the upper tier as well, but people have no idea. People don't know the consequences of having the two-tiered system.
Interviewer
What are the consequences?
Jay Moreland
Well, in the newspaper today was a story about the flu vaccines (front page), having to be thrown away. And the fact that those flu vaccines didn't get to the health department until December, and when they were doing their push to get the flu vaccines given in September, October, November... that kind of stuff, and what really happened there was the first tier, the upper tier got their flu vaccines really well, so the big shopping places like Walmart and things like that got all of their flu vaccines. My wife was an OBGYN--they got all of their flu vaccines, and guess who was at the end of the line? The end of the line is the other tier, and that's the group that didn't get it soon enough and it got distributed so late in the flu season that a lot of those doses went unused and now get to be thrown away, and as a direct result of having a two-tiered system. I mean I was so desperate that I was lamenting the fact to my wife, who is an OBGYN, and actually, you know they had an overload of flu shots and they actually donated several hundred doses to our clinic. Now that's just because I was complaining about it to my wife who happened to have extra access, but you know it doesn't have to be that way. You know there are 36,000 people who die from the flu every year in the United States--that's ten Iraqs every year who die from the flu, and we have one of the worst flu vaccine distribution systems in the world. There are thousands of people dying from the flu because we can't get it right, and what people don't realize is that all of those people who aren't getting the flu vaccines also don't have the protection that they stay home from work when they have the flu. Guess what? That restaurant worker is going to go to work sick with the flu preparing your food, and my food, or you know basically spreading the flu epidemic to the rest of us anyway, and it's because we have a two-tiered system and because the lower tier doesn't get what they need to prevent the flue, we have big problems with it spreading to the rest of us.
But we don't do a good job of getting vaccines even to the second tier truthfully. Even in the age over 65 we like to try to get the most vaccinated and we're not doing a very good job in those populations and you know those are insured Medicare patients--we can't even get them to them. In my patients... my Medicare population in my clinic I couldn't get it to them because of this inequality of distribution, and it's purely a response to the fact that this is a for-profit medical system and they sell the expensive single dose stuff to the high end places first and then for us to buy in bulk to try and save pennies and we get it last.
Interviewer
What are your frustrations working with in this system?
Jay Moreland
Well the frustration is is that I know that there has got to be a better way. I also see, you know... it's a two-tier system until somebody is dying. When somebody is on death's doorstep, then it becomes a one-tier system--then we pull out all of the stops and try to do everything we can--we spend all this money in the ICU to try and save somebody's life. It doesn't matter if they're insured or not, we just really pull them out of the pit no matter whether they're insured or not. But did we do anything to keep the person from falling in the pit in the first place? And what's frustrating to me is as a society ethically we've decided its o.k. to let the person fall into the pit, and then pull them out and spend all of these resources pulling them out of the pit, but it's not o.k. to prevent them from going into the pit when it's less expensive. That's what's frustrating.
Interviewer
So who are the people that you see every day?
Jay Moreland
In my particular clinic I think we're around 70-75% Spanish speaking and the rest about... most of the rest of that 1/4 I guess are Caucasian, but we do have a fair mix of immigrants from other countries as well; Somalia, Afghanistan, Serbo-Croatia. We have some from Vietnam, Pacific-Islanders, Native Americans. We also have the contract for the Walk-in Indian Center so we take care of a fair number of Native Americans--a whole real mix. But of that 70-75% who are Spanish-speaking probably 2/3rds are Mexican immigrants and the rest is sort of a smattering from all over, which is fairly typical for the rest of the United States in terms of that particular population. We tend to have maybe a few more from Central America and South America as opposed to like Florida tends to have more Cubans and Puerto Ricans or New York more Cubans and Puerto Ricans and because of where we are in the United States we get more of the other groups of Hispanics. Fifty-percent uninsured, about 50% insured right now... we have I think 5-10% Medicare which means over 65, but also a lot of our uninsured have no Medicare in their also... elder. A large number of children... we take care of the full range from babies all the way up to end of life to real, real old. We deliver babies--do a lot of prenatal care taking care of pregnant moms and then taking care of their babies afterwards and we really try to take care of the whole family once one person is in our clinic who is a family member, we consider the rest of the family ours if they want to be so we really try to take care of and get to know the whole family and I have multiple generations that are in my clinic where I take care of grandma and grandpa and mom and dad and kids and sometimes great-grand kids and that's really quite satisfying. We have quite a number of disabled individuals. Disabled individuals are sometimes sicker or they're disabled because they're sick, so we have a good number of those certainly in our clinics.
Interviewer
So a typical patient might be a pregnant Latin-American woman?
Jay Moreland
Absolutely. That's fairly, sort of the root beginning. In our particular area we have a lot of immigrants in this area, in this part of Utah there has been a big boom of immigrants to this area from Latin America because of the boom in... Particularly you know construction and? jobs and things like that and so those individuals who tend to immigrate are those twenty-somethings who have lots of immigrant vigor, you know they come here and meet each other and start to have babies and so that's sort of the typical family that I have is a working immigrant family--maybe the father of the baby is working in construction or in a restaurant or something like that, and maybe mom's working as a hotel maid or something like that and you know now we have babies being born and family issues. A lot of times they come in family groups where I have brothers and sisters who've come together and help boot-strap each other and sometimes they're sharing housing and all of that, so it's interesting... a very vigorous group of individuals. The people who are in my practice are hard working, ambitious, you know want to live the American dream kind of people who really come here because of the jobs because it's such a great... you know we have a booming economy. Where are you going to go? Where the jobs are.
Interviewer
It makes sense. What do you say to people who say we shouldn't be providing medical services to people especially if they're undocumented?
Jay Moreland
So we prefer that they get the flu and get the rest of us sick with the flu or get our kids sick? You know you don't want to vaccinate the kids? You want them to go to school and get the measles and then pass the measles epidemic around? Again, if they fall into a pit, we will pull them out no matter what the cost. You know if there is a big car accident and somebody is bleeding to death, we'll go on in there and life-flight them to the University or we'll you know... Intensive Care Unit, you know heart attack or whatever, we're going to save their life. That's our ethic. Our ethic is to save their life. If we're going to do that and spend lots of money doing that, why don't we want to do the other stuff? I don't get it. I mean I'd almost rather do the upfront stuff and spend less money and save lots more lives rather than always only focusing on pulling people out of the pit. That's kind of one side of the coin, the other one is these aren't lazy people, these are working people and they are working to do jobs that are hard to do and there is obviously a need--they get hired. They are part of our economy. They pay taxes. They may not be able to vote, but they pay taxes. They are part of our economy and they're part of our society. We can argue about whether or not they should be here or not, but I feel like they're here. They come to me because they need help, and I don't differentiate if somebody is insured or uninsured. Fortunately I'm in that position where I can do that, but these are human beings... I can't... how could you turn your back on somebody? If it was your brother or your sister...? And they are, they're our brothers and our sisters really. I don't see any other way ethically. I just think it's something that we need to do. Now we can decide how much we're going to do and we can say well this much o.k. and more maybe not so good. I think that's reasonable. But we ought to decide what's the right amount to do.
So we need to decide how much is the right amount to do, and I think we need to say, o.k. we have this much and we think it's the right thing, the ethical thing to do to take care of this much and no more. And anything above and beyond that can be the two-tiered system. If you want your plastic surgery and you got the money, go for it. I mean obviously we're not going to be paying for something like that for the masses, but these are productive people who contribute to society and I think we need to support them. On the other side of that we're competing against every other nation in the world now and all of the other major industrialized countries are taking care of this as a national priority, and so that money is not taken away from the businesses, and therefore businesses compete far better than our companies do because of that national priority. Just ask General Motors if they would like that.
Interviewer
And you really don't discern between documented and undocumented?
Jay Moreland
No, that doesn't... no we don't... don't ask. Again my job is to take care of human beings. It's not my job to be an immigration officer--that's a really hard job for them and there is an army of people who are out there to do that. If somebody made it my position... if somebody passed a law and made it my position to do that, then you'd have people not coming to the doctor with things that need to be taken care of and we'd all be worse off. If they were afraid I was going to do that... no, so absolutely... we have never, ever... as a matter of fact we are a safe zone and we're treated as a safe zone by everybody. I mean people say, oh you're working in that bad part of town and everything like that and ya we have some difficulties with crime and things like that--we're in a very poor part of town, but really we're in a safe zone. People treat us nice. They take good care of us.
Interviewer
You said you like taking care of the entire family. What's the reward... what's the joy in doing that?
Jay Moreland
Your patients become more like friends, and they really are. You take greater joy in hearing what's happening with their kids and watching them grow up. That's a great joy. To help a young couple who has a brand new baby learn how to become parents and give them advice, especially when they're go far away from the rest of their family... sometimes you're the only advice giver for this new family and it's quite gratifying. It's more than just healthcare. One of the things we do is we give out books to kids from age 6 months to 2 years--it's called Reach Out and Read. We hand out these books and talk about the importance of reading and talk about how that prepares the child to learn better. It creates a desire to learn and to read. And the studies show that kids do better in school and they stay in school longer and with much, much better academic outcomes. Well you know I feel like I'm preventing gang warfare or gang people you know going that route. If I'm helping teach parents how to be better parents, that can be a good thing. Taking care of mom or dad's depression helps support the rest of the family so that they can be a better father or mother, so that they can keep a job, or helping somebody kick the habit of alcoholism... you know that affects the whole family, and sometimes your entry-way into taking care of a medical problem is through a child. The child is obese, you know, and the parents will pay more attention to you when you talk to them about diet and exercise with the child and then you say, but this is for all of the family and you guys should all be doing this and you should be setting an example. It's amazing how many more parents... if it's just an adult you talk to they say, oh whatever, but if it's for their kids sometimes it's more powerful to them where they really see that their behavior and how they run their lives is affecting this child and so the most fundamental change for health; diet and exercise is a family issue and grownups set the tone in the family. There is no way around that. So it's very gratifying when you see growth and you see an opportunity to have an effect. It can also go the other way around--you can remind a kid don't forget, make sure your mom and dad are wearing their seat-belts, and kids will do it and you know that well you may never know that you're saving somebody's life, but you know... and that's particularly in the Hispanic community--that's how families work, that's how life works is you have this family unit, and many, many cultures are like that. It's much more powerful if you really look at it from the holistic, you know, big picture view and in context of where they're working and what their stresses are in the family, and that's much, much more gratifying. I mean it's really, really easy for me to write a prescription and say see you later, but what's really gratifying is feeling like you're really having an affect on something that could have a good outcome for somebody. It's really gratifying to help people stop drinking and see the positive affects in that family. It's not with a prescription pad that you do that
Interviewer
One thing we want to talk about are the cultural barriers that people face in terms of access to health care. What do you find? What are some of the cultural barriers?
Jay Moreland
Cultural barriers are a big deal. I think the language barrier is probably bigger--that's hard to get around. Cultural barriers can be significant depending on which culture you're talking about. If somebody comes from Sudan and you're prescribing... you know handing somebody a prescription they might say, why are you handing me this piece of paper. So what is that cultural? Well some of that is not being exposed to the western medicine model, and so that can sort of be a barrier. Cultural barriers are more along the lines of sort of explaining how certain illnesses work or certain parts of life work and letting people know what our culture is like and why we're doing it the way we're doing it currently, but then also being able to understand where the patient is coming from can help you engage their own cultural power. So for example in the Hispanic community the idea of the elder having respect and sometimes then if you have new parents you have a teachable moment when you have your grandmother there to talk about certain things. Now grandmother becomes your ally. In other cultures that's maybe not quite so important. On the other hand if you get grandma angry or say something that's not agreed with then it can also work against you as well. And sometimes there are long held cultural beliefs that work against what we know as good practice. For example, the idea that you need to use the bottle a lot for a newborn baby to try and fatten that baby up as much as possible. Well that's a common belief in a lot of cultures; Hispanics and some other cultures as well, maybe Vietnamese, that interferes with the breastfeeding process, but is that cultural? It's a relatively new cultural thing but you could call that a cultural thing, so that has health outcomes. You have sicker babies if they don't breast-feed, so dealing with that is sometimes very difficult. It's not something that always works just one patient to the next. You can talk to the patient about the importance of this, but if the rest of that family is saying keep giving him the bottle, the baby needs more, the baby's still hungry, you have a lot of other factors that can influence somebody's medical decision making or whether or not they're afraid to take their medicines because they're afraid they'll be addicted to their medicine even though it's a blood-pressure medicine. You know I can explain to them you can't get addicted to that. If they've grown up in a family or a society where you know any kind of medicine you can be addicted to, you can really take a while to work through that. Now is that cultural or is it just not being educated about what's the reality?
Interviewer
As a doctor, are you trained to deal with people from all different cultures?
Jay Moreland
Certainly in most community health centers they really try to train the practitioners and all of the people who work in the clinic to have what they call cultural sensitivity, and some of that is a knowledge base thing where if you work with large numbers of a certain population knowing what some of their cultural ways of thinking and ways of operating is an important thing to get trained in specifically, but then because we get people from so many different areas then it becomes, you know, having your antennae up and having to be sensitized to cues that can sometimes even be different from society to society in terms of what kind of verbal and physical cues you're getting from patients, and then asking... so it's not only having the... you know just being sensitive to how somebody is responding to your interaction, and seeing if you're getting that eye contact, but it's also finding out where they're coming from and what are their concerns, so we're trained to really try to ask questions in a such a way that you're not limiting the ways in which the patient responds. They talk about opened ended questions. You're really good at this because you're an interviewer so you know about closed ended questions or like a yes or no question, or factual, very factual where open ended questions are, you know, what do you think about this or that? That allows somebody from a different culture to sort of fill in the palate for them works and if you allow people to express themselves in that way, then you can get an idea of maybe what's the best way to help them. So that cultural sensitivity is not just their culture but their family culture as well because different families from within a culture may have very, very different approaches. You know you could say that about people from the United States--very different.
Interviewer
So it sounds like it's more being in tune and open and listening and not assuming what people need.
Jay Moreland
Yes, and that's knowing where your own cultural blind spots are is important so that you can know how to stay open to what people are trying to say. Sometimes it can be very subtle in the way they say something or the way they use their language. That's why I say sometimes the language barrier is part of that.
Interviewer
Why do you do what you do? Why do you choose to work at a community health clinc?
Jay Moreland
Because it's fun. I tell people, you know I don't need to watch soap operas because my job is so interesting. When you work in a community health center, it's really true no matter what position you work at a community health center, whether it's the C.E.O., whether it's the accounting department, whether it's the medical assistant or the doctor, or the front desk or whatever, it's really true that you have to know how to do more with less. Because you have patients with limited means and limited communication skills and lots of limits, you have to figure out how to do more with less, so as a family doctor I get to do more of what I was trained to do, you know--take care of a wider variety of problems. Sometimes, you know, it can get a little uncomfortable where you're reaching the limits of your comfort zone and then you say, well... When I approach a patient who is not insured, I try to, as much as possible, treat them in the same as the insured in the sense that I say, "And here's the point where I would ordinarily refer you to a specialist, and I think that's a good idea. I know that you're uninsured, is this something that you can afford?" And usually the answer is no when I tell them how much it's going to cost, and then we say, "well o.k. or we can get you the? Program or some other program, o.k. If we can't do that well let's try this and we'll see you back in a week or two." It's a real enjoyable challenge to work through those. It keeps your brain working. And patients can't with money necessary, but they pay with gratitude. They really appreciate that and so it's a feel-good kind of a job. You don't work in this job, no matter what part of the company. You don't work in this unless you get a little bit of a charge out of that. You get a real gratification out of really feeling like you're making a difference.
Interviewer
You see a lot of pregnant women, and deliver a lot of prenatal care. Do you see that making a difference?
Jay Moreland
Yes, we've actually done studies--we did a study that showed that we decreased our low birth weight and premature baby rate. Our rate of premature and low birth weight is less than the Utah average and we're a high risk clinic so I think our rate is like 7% and Utah average is something like 9% so we do a pretty darn good job of preventing that, and those are expensive babies. I mean they can cost a million dollars for babies, you know, not unheard of at all, so put a little bit of money up from to prevent that. I don't know. It seems like it's a good investment to me.
Interviewer
You've been at the clinic for quite a while. It seems like the financial struggle is something that keeps cycling through. Just describe that a little bit--that constant financial struggle.
Jay Moreland
Well I've been there twelve years and this is the third financial crisis that we've been through where we've either had to lay off people or weren't going to make payroll, or you know had major restructuring that was going on or mass amounts of people who were leaving because of the draconian changes that were being proposed, and it's a... that can be quite stressful to go through that, I mean, you know imagine being told, well your paycheck for New Years is not going to be on time, it will be a little bit after that that you'll get your paycheck you know. That happened, you know. We're at the whim of some political winds that blow so sometimes we do a little better and sometimes not so well because of the politics and the way findings change and it just makes its very hard to do what we do, I mean the bottom line is the people who work there are very committed and we do get paid less than what the going rate is for almost anywhere along the organization, whether it's a medical assistant or a doc or a C.E.O., you know. Fortunately we have very committed people, but it's a real struggle to do the right thing and to do the right thing for as many people as we can, and literally when you go through that financial struggle, you have to clamp down on the uninsured and close your practice down to new uninsured and you know you try to let in more insured patients, but when you fill your practice up with more insured patients, it means there's less room for the uninsured. It hurts to have to do that for survival--to fill like that's the only way to keep your doors open.
Interviewer
You're not seeing any new patients there right?
Jay Moreland
New OB's is the only thing we're open to at our clinic and the newborn babies.
Interviewer
So if the uninsured call up your clinic, what happens?
Jay Moreland
Basically... I'm not sure if some of our other clinics still have some openings, so we might try and send them out to one of our other clinics, but basically they're out of luck. You know the kids can go down to the health department and get their shots, you know but there are not many options, there's really not. There's a few pretty small... like there's a school-based clinic in Rose Park but it's really, you know tiny and if you're a diabetic forget it, you know. It's rough.
Interviewer
Are we doing enough as a state concerning the uninsured?
Jay Moreland
It depends on what your definition of what enough is. My definition of enough would be take care of all of the uninsured and some of the basic health care needs. That would be what I would define as enough is basic, universal healthcare for all and basic, and you can decide what's basic. But I would like to see that, and for me that would be enough. Anything shy of that is not enough, but that's how I define it.
Interviewer
There just aren't enough primary care docs...
Jay Moreland
It's the end result, I believe, of healthcare as a business. If you don't pay somebody very much, not a lot of people are going to do it and also if you cut the funding for the primary care training programs, then you're going to have less of those, so there's people like... you know putting catheters into people's hearts and you know doing major surgeries and things like that because it pays pretty well. So as a medical student you have a choice, let's see you can become an orthopedist and make lots and lots and lots or a family doc and have really long hours and not get paid so much, hmmmmm. So there's some inequity there and maybe there always will be, but these are policy decisions, I mean the way that it all has sorted out has been because of the way our healthcare is structured... you know it's a two-tiered system and we're going to put tons of money into the upper tier to pay for pulling people out of the pit when they fall in and really, really expensive stuff to pull them out of it--we'll throw one hundred dollar bills at them until we get them out of the pit, and there's going to be plenty of doctors to be around to pick up those hundred dollar bills in the pit, but the primary docs are trying to keep people from falling into the pit--they're not throwing money our way or certainly not enough, or there would be more of us keeping people from falling into the pit.
Interviewer
Is our healthcare system broken?
Jay Moreland
Well look at other industrialized countries. Look how much they spend and what they get for what they spend. The other countries are far better at keeping people from falling into the pit. Our country is the best at pulling people out of that deep, dark pit. We're really, really good at intensive care, you know and helicoptering people in to save their life from their care accident. We're really great at that, but overall we have more people dying from the flu per capita and from a lot of other diseases as well--infant mortality. We have a really, really high infant mortality rate and it's... you're not going to decrease that infant mortality rate by putting more money into NICunits... (Neonatal Intensive Care Units). It doesn't work that way. You can throw all of the money into that pit that you want, but it's not going to keep people from falling into it.
Interviewer
What will keep people from falling into the pit?
Jay Moreland
Deciding as a society what's the right thing to do? What's the ethical thing to do and what do we think is the right amount of healthcare for everybody? And we'll also have to decide that maybe there are a few things that will only be for people on the upper tier. I don't see any other way personally other than doing that. Again with the flu shot... if we don't as a society decide that we're going to distribute flu shots in a systematic public health oriented way, then it will always be a two-tiered system and you'll be able to get it at the rich doctors office, but you won't be able to get it at the Health Department. The reason why we don't have enough flu vaccine is not because we don't have Health Departments who are willing to buy it or stock it, it's because it's not cost effective for companies to make cheap flu. They lose money on the flu selling it in bulk. So of course they're going to sell it to the rich doctors first to make their money.
Interviewer
Is there anything that you would like to add?
Jay Moreland
I just wish that people would realize that everyone in the United States is uninsured in the sense that there are a lot of things that are wrong about our healthcare systems that we are not insured against--that running it purely based on profit is not the way to keep people from falling into the pit. In order for things to work out right, in my opinion, we need to decide that there is a certain amount of basic healthcare that everybody needs and the only way to do that is to set up a system that is national--that there's a minimum national standard--this is what everybody gets no matter whether they're rich or poor, and if we don't do that we're going to have more and more people falling into the pit and we'll be throwing our money down there and that's more expensive. It has been shown all around the world that that is more expensive... that's why our healthcare is worse than the rest of the world--a lot of the industrialized countries, because we're too focused on throwing money in the pit, and not enough in keeping people out of the pit.
Interviewer
One last question... when you were in medical school you could have gone into a different specialty. Why did you follow this road?
Jay Moreland
Just call me Don Quixotic. Show me a windmill and I'll go after it. Fortunately for me I'm married to an OBGYN and private practice is really the main bread winner in our family so you know if it was a different situation then maybe I would be forced to work more in private practice or something like that. I love doing the variety of things that I'm able to do. I had somebody... one of my professors told me in medical school, oh you're going to be so bored, you're going to just see all of these sore throats and runny noses and you're going to be bored. No!... It’s very interesting!
