By RangelMD
Contrary to popular belief,
those without health insurance are not flooding emergency rooms as a
consequence of being cut off from routine and preventive care. Actually,
frequent visitors to the local ER are far more likely to have insurance
according to a new review of 25 studies on ER use published since 1990.
Frequent
users account for about 8% of ED patients but 28% of visits. Although frequent
users are not a homogeneous group, 60% are white and their average age is 40.
Roughly 60% are enrolled in Medicare or Medicaid.
The
uninsured do not dominate EDs; 15% of frequent ED visitors have no coverage,
the study found. Only about 2% of uninsured adults visit an ED four or more
times in a year.
Medicaid and Medicare
beneficiaries younger than 65 tend to follow the “if you build it, they will come”
economic model of health care utilization. Without insurance, people tend to
avoid large health care costs for everything except actual emergencies. Given
an entitlement in the form of low cost government health insurance, they tend
to seek out care for every ailment like a millipede with a thousand-for-one
free shoeshine coupon. This phenomenon was clearly seen in the disaster that
was TennCare, Tennessee’s attempt in the later 1990s to expand their state
Medicaid program to cover everyone under the age of 65.
It’s unclear
why public insurance beneficiaries tend to be ER “frequent fliers” at much
higher rates than those with private insurance. Undoubtedly, those in lower
socioeconomic standing tend to be in poorer health, have more chronic health
problems, and hence be more susceptible to the consequences of risky behavior
and poor health decisions. But most of these frequent ER fliers with public
health insurance have primary care doctors so having access to care should not
be the problem.
Or is it?
Even with
public health insurance, these patients are still likely to be victims of
poorly designed, underfunded, and overcrowded health care systems in intercity
and impoverished rural areas.
Public
insurance programs like Medicaid usually pay health care providers a fraction
of what private insurance policies do and so there are usually significant
shortages of physicians in communities where these patients live. What access
does exist tends to be either private clinics where the doctor runs a treadmill
style practice of seeing 50 to 60 patients a day for less than five minutes a
visit in order to maximize profit or there are public clinics staffed by health
care providers on salary who have neither the incentive nor the time to provide
quality care for a population that is often plagued by multiple chronic health
problems.
Either way,
getting an appointment to see a health care provider in an undeserved area for
an acute illness is often an exercise in futility. Few of these clinics offer
after-hours or acute care same day service so often patients have no choice but
to visit the nearest ER, even for something as trivial as a bad cough. Without
additional funding incentives to expand urgent care access in these areas, the
hospital ERs remain the only facilities that are designed and staffed for this
purpose. And it’s only going to get worse.
The Patient
Protection and Affordable Care Act may pour hundreds of billions more into
expanded Medicaid, Medicare, and subsidies for health insurance to help cover
up to 35 million more Americans. Presumably, many of these patients will enter
into the same poorly designed, underfunded, and already overcrowded health care
systems, thus worsening the situation, and leading to more ER overcrowding.
That expanding
health care coverage would lead to more ER overcrowding is paradoxical until
you look at the reasons for why ERs are overcrowded in the first place. The
solution to the problem caused by the solution to inadequate health care
coverage is to adequately fund community health systems in order to provide
incentives for the private sector to build more urgent care and minor emergency
centers.
This,
in turn, would hopefully take a large amount of the load off the ERs so that
they can concentrate on actual emergencies. Unfortunately the Patient
Protection and Affordable Care Act seems poised to do exactly the opposite; to
provide just enough funding to get more people into these systems but not near
enough to expand the infrastructure of these systems.
