Ask around the Waco medical community for an authority on what’s wrong with the American health care system — especially as it touches the low-income and uninsured — and fingers point to Dr. Roland Goertz.

He is the executive director of the nonprofit Family Health Center, which serves some 19 percent of McLennan County’s population at a dozen clinics. Most of its patients are within 200 percent of the federal poverty line, about $44,100 for a family of four. The center also has a medical education program that has trained half of Waco’s doctors.

Under Goertz’s leadership, the Family Health Center became a Federally Qualified Health Center in 1999, ensuring its financial stability and helping it expand its patient load more than 150 percent over the last decade. About 38 percent of patients are uninsured, but with the help of local government funding, the center offers them a “good health card” that assures them affordable primary care based on a sliding pay scale.

Goertz, 54, has been a national advocate for affordable health care and for primary care doctors. He serves in numerous state and national organizations and is a board member of the 94,000-member American Academy of Family Physicians, which in 2006 honored him with the Robert Graham Physician Award.

A Smithville native from Bastrop County who started his career as a country doctor, Goertz earned an MBA to go with his MD. He speaks often to civic groups about the economics of health care. In an interview last week with the Tribune-Herald’s J.B. Smith, he chronicled how the American health care system has encouraged expensive treatments and procedures while discouraging what should be a cornerstone of health care: The family doctor.

Here’s some of what he had to say:

Q: Based on your experience, what is the profile of the uninsured who come here for care? How are they different from what we assume?

A: Some are who you think they are: people who are homeless or have fallen on hard times or, for whatever reason, can’t hold a job. But the majority are the working poor, individuals who have jobs but no coverage.

The portion that has been growing fastest over the last 10 or 12 months are individuals who at one time had coverage but, because of skyrocketing health care costs or because of previous illness or because they moved here and don’t qualify, are now uninsured.

Q: If the Family Health Center is doing a good job of taking care of the uninsured, why should we worry about the uninsured? The system’s working, right?

A: It’s working here, because you have a commitment from everybody. We don’t provide all health services. We don’t provide hospitalization. And we don’t have a way to cover specialists. But they’ve all been good in helping us. As long as everyone shares in it, we’re going to keep making it work. But I’m worried that because there’s not enough offset for hospital and specialist costs, we’re going to get to a place where we are not attractive because of the cost of uninsured care. It’s a bit of a house of cards. It could cave in on itself.

Q: So now you’re seeing people working but losing coverage from companies.

A: What I’m seeing more is working-class people, ages 25 to 44, people who may have positions that are less technically driven. If you work in a restaurant, for example, you’re going to have a high likelihood of not having coverage. For businesses with fewer than 20 employees, it’s very difficult to get a health plan that’s not extremely expensive.

If you’re a business and your rates are going up, you can only do three things. You can compete your bids and hope to find another health insurer, but in McLennan County today there are maybe three or four options, and your success may be limited. Second, you can offset the cost of coverage onto your employees. Or, third, you can take away benefits.

Q: We may attribute some of the high rate of uninsured to the recession. But the fact is the cost of health care has gone up at a rate that exceeds the rate of inflation. In the long term, are we going to see a trend of more uninsured?

A: I don’t see how you can avoid it. If you look at numbers, it’s scary. Every year health care costs have gone up higher than the cost of living, (plus there has been) a reduction in salary increases or raises for that population. The employer out there is already being affected. Can it continue? In reality it can’t.

There was an article in the Wall Street Journal recently that took this position: Who cares if the amount of spending that goes to health care goes up to 30 percent? That’s a wealth creator’s perspective. It ignores the health creation side. From the wealth creation side, if I’m invested in health care, heck, yeah, I want it to go to 30 percent. That’s how I make money. Why would I want less? But if you’re looking at it from health creation or the cost-containment side, you’re going to have to attack the wealth creators’ side. That’s why we have this huge debate. Nobody wants to give up anything.

Q: Will extending universal coverage to everyone solve the problem?

A: No. It’s just a piece of the problem. What it addresses is a long-term, not a short-term issue. We keep confusing the two. Giving coverage to people over time gives them better health and less cost of care, but it doesn’t do it in a year or two. The numbers that support that are pretty irrefutable.

(In a study of Medicaid patients), people were asked if they had a personal physician. If you answered yes, it reduced costs 15 to 19 percent just by having a personal doctor, because someone can coordinate your care. Covering everyone long-term will result in a healthier population that’s more productive. But you’re not going to fix the problem until you change the model of care delivery. If you want to change the results of the health care system, you have to change the model of care delivery. Very little is being promoted to change that model, and I’ll tell you why: That attacks the wealth providers.

Q: Isn’t this the problem with health insurance as it now exists — that it creates a moral hazard in which the doctor, the patient, the hospital and the medical equipment-maker all want the most expensive treatment? If I as a patient don’t have to pay for that mobility scooter, if someone else is going to pay for it, well, why not?

A: That’s exactly right. This is a country where we love our choices, we want what we want. The system is getting exactly the results it was set up to do. What you have to do is change the payment system to make it less inflationary, that doesn’t reward simply doing more. That’s going to be debated because people are going to fight that.

Q: Do we need to shift attention from specialists to primary doctors?

A: What I’m saying is, give me and anyone who interfaces with the patient more information (about costs and benefits).

The very first coronary artery bypass was done in 1959. It was approved and done on the basis of the theory that it should work. We proceeded to crack open a lot of chests and do a lot of bypasses. We spent $6 billion between 1960-1966 before there was any study to decide who should get the procedure. We really can’t afford that.

Q: How did we get in this situation of medical inflation?

A: It was really driven by hospitals and hospitalization insurance.

After World War II, some entrepreneurial doctors in the Midwest developed the first hospitalization insurance plan. But you had to be sick enough to be in a hospital to get coverage. It took off like crazy. There was almost no cash in this country after World War II. So employers started offering insurance as a way to attract employees. That gave the wealth creators a wonderful window of opportunity.

Primary care doctors, the old GP, were not included in that. My ancient ancestor, the GP, always faced you directly and said, “You owe me $6.” There was pressure to keep that cost down. But on the other side, the hospitals and surgeons were saying the employers are paying for it, so let’s keep evolving and growing this thing. That model has not substantially changed since then. You’ve had a growing disparity as a result in what different types of physicians are paid.

The other creation was what I call the academic-industrial complex: The medical schools aligned with the wealth creation side. The wealth creation entities needed to have medical school research. And as states have cut or frozen spending to medical schools, the schools no longer have the incentive to create doctors for the state. Basically, what medical schools have done is create those physicians who benefit them most.

In 1965, Medicare comes along. It was a huge debate, everybody was angry at each other and the American Medical Association said it was going to be socialized medicine. When it passed, they didn’t have payment methodology. They simply adopted the health insurance model and etched it in stone.

Q: So that perpetuated the system.

A: It made it worse. Now there was a system in which procedures were paid for. Inflation is built into the system.

Q: Do you think there’s a way without completely changing the system that you could incentivize primary care?

A: The elements of this have been known for 40 years. Slowing things down allow those who don’t want it to happen to mount a bigger fight against it. What is really exorbitantly paid for is not specialty care vs. primary care, but procedure vs. thinking. Medicine is the largest industry in which doing something is paid for much more than thinking. If I do a test, I get a huge reward, whether you get well or not. You need to shift payment over time toward cognitive efforts. But it will be tough.

Q: Is there anything here at Family Health Center that would be a model for that, or is this a special case?

A: We have to play some games, too. For us to be successful, we have to see lots of patients as efficiently as possible. The exception for us is that we have grant-funding that isn’t tied to doing procedures, but does allow us to see patients for care.

Q: Are the proposals in Congress right now a step in the right direction or do they need to be completely redone?

A: The Senate Finance bill is a much more moderate bill that upsets each extreme so it must be better. They have focused more on insurance reform.

Q: You know the medical community here. What is the tenor of their reaction to the health care bills before Congress?

A: The majority of doctors do want something to improve the system. . . . The average care doctor spends $70,000 worth of their time a year filling out paperwork for insurance companies. . . . That’s asinine. It’s a game, but it’s someone’s salary. You could eliminate a lot of that stuff.

We pay 40 percent more per capita for health care than the next most costly country. We have the best acute care system in the world. It’s true. If you have a serious illness in this country, you get cared for better than anywhere in the world. But we don’t have a very good wellness system. We are very happy to assume that I can do anything I want to myself, and the system will fix it. The reality is we can’t.

Q: You’re saying that if you just add more insurance coverage, and nothing else, costs would continue to spiral out of control?

A: It would crater the system. You can’t just add more coverage. You have to change the model.

Q: In the short term, for the center, having 99 percent of people in McLennan County covered would take the pressure off you?

A: Sure. If you cover more people, it would be a transition. It also depends a lot on payment model. If the reward system stays the same, it’s not going to help a lot. It has to include some kind of provision for changing the current reward system.

Q: Do any of the bills in Congress do that?

A: None go that far. They can’t go that far right away. It would have to happen incrementally. To do it suddenly would create system shock.

If you covered everybody, you’d get this huge bump (in costs), then over time you’d get some success in controlling costs because of increased productivity and a healthier population. If you want to bend the cost curve, you have to change the reward system at the same time.

It took 40 years to get us to where we are. We need to at least start to change back to where we want to go. We have much less than 40 years to get there. Ten is the magic number. Sometime between 2014 and 2017, Medicare goes broke under our current model.

Q: So we’re headed toward a crisis?

A: Yes, you’ll have a crisis in some form or fashion. From an economic sense, if you keep shifting dollars to health care from other industries, you will inevitably drive those other industries outside the country. There’s no way around that. It’s a zero-sum game to some extent.

Q: So if we’re spending that money on health care. . .

A: . . . then you’re not spending it somewhere else. If health care cost increases are greater than general inflation, by definition you’re taking money away from some other sector. Which sector do you want it coming from?

Q: Most of us couldn’t tell you how much of our paycheck goes to health insurance, or how much our last doctor’s visit cost.

A: That’s where the cultural change has to come from. Culturally we have to value being well. If you can get American society to value being well, you’ll make a huge step in the right direction.