Can single payer revive our ailing emergency departments?
Andrew D. Coates, MD, Albany Medical Center
Empire State Emergency Physicians Interim Communique (EPIC)
Published by New York State Chapter of the American College of Emergency Physicians
Vol. 26:02:08
The emergency department provides a crucial vessel for our communities, an entity into which, on a moment’s notice, each of us might need to pour all of our hopes and fears. Yet our emergency departments share night and day, the frustrating, often tragic personal and social costs of our present predicament - the progressive failure of a system dominated by private health insurance. Patient demand for ED services soars, yet the number of 24-hour EDs declines and reimbursement for ED services dissipates. Ample study demonstrates that emergency department crowding undermines quality care, but still the problem worsens. In the words of the Institute of Medicine, “the nation’s emergency medical system as a whole is overburdened, underfunded, and highly fragmented.” A 2008 study in Health Affairs finds that ED wait times have lengthened. Ironically, the largest increase in waiting time was experienced by patients for whom EDs are pathways of expedited care — those with acute myocardial infarction. These patients waited an average of only 8 minutes in 1997, but 20 minutes by 2004, a 150% increase. One out of four patients with acute MI waited 50 minutes or more before seeing a doctor by 2004. Overall, ED wait times were found to be 36% percent longer in 2004 than in 1997.
The fact that 47 million Americans had no health insurance during all of 2006, and that tens of millions more have inadequate insurance and/or shorter periods without coverage, weighs especially heavily upon the ED. Non-urgent care in the emergency room has boomed, yet this is not the root cause of crowding in the ED. Instead, bottlenecks caused by the intense needs of a few patients result in ED crowding — even one critically ill patient waiting for an ICU bed can trigger a cascade leading to a significant back-up for all patients, for hours, even days.
Sadly, where the percentage of uninsured patients tends to begreat, specialist availability tends to be most scarce, increasing the likelihood that a severely ill patient will need to go on to another hospital for inpatient care. This introduces risks of delayed care and impacts upon the care of other patients. More depressing, some doctors try to avoid being on call to the ED. But how does our system of private health insurance reward physicians and surgeons who accept the responsibility for highly acute, complex, high-risk patients during off hours? Medical and surgical resources shift away from the hospital, away from the ED, with mighty financial incentives. Witness the development of surgical care facilities outside of the hospital and hospitalists inside the hospital, further fragmenting the continuity of care. And then where will we send the patient without health insurance, who has had no doctors, for follow-up? Meanwhile hospital administrators see the ED less as a “vessel of hopes and fears for the community”, and more as a failing “cost center”— a place to cut corners in order to limit losses; a place where everyone should be kept as busy as possible. The leaders of the hospital are merely obeying the rules of a system designed to serve insurance companies, whose leaders in turn serve shareholders, not patients.
Of course too many patients — patients with health insurance! — do seek primary (non-urgent) care at the ED. For we practice in the shadow of what the American College of Physicians has called “the impending collapse of primary care
medicine.” Witness the growth of “urgent care” walk-in clinics for these paying customers. Add the observation that the percentage of uninsured in America has risen steeply — but the percentage of uninsured who seek emergency care has remained relatively flat.
Consider how in the American “system”, private insurance companies dominate payment structures. Since one or two large private insurance firms dominate every local market, and most patients in the ED have private health insurance, these companies thus hold extraordinary power over ED resources, indeed the community’s resources.
Finally, consider that state-based and other incremental reforms, SCHIP for example, have failed to reverse these trends. SCHIP could not be expanded fast enough to keep up with the children whose parents lost their employer sponsored health insurance.
In a bellwether experiment that is headed toward disaster, Massachusetts has tried to mandate universal access by making it a crime to be uninsured. While the plan has succeeded in getting working families of meager means to sign up for state-subsidized plans, it will sink under burgeoning costs. The Massachusetts experience takes on extra significance this year, for both leading Democratic candidates center their health reform proposals on mandating the expansion of private health insurance, a notion originally put forward by Richard Nixon.
Massachusetts has been able to reduce the number of uninsured. But of the more than 340,000 new enrollees, the lion’s share receives state-subsidized coverage, including more than 55,000 new to Medicaid. Of the uninsured whose incomes are high enough to be “mandated” to pay for their own private health insurance (or else pay the state a fine), only 7% have done so. (But who can blame them, when cost of an individual plan is nearly $7,000 a year and a family plan twice as much as that?) Massachusetts now faces escalating premiums, co-pays and deductibles, a budget shortfall of at least $100 million dollars and the political impossibility of new taxes. Not only will the program fall far short of universal coverage, we may witness a collapse on the scale of TennCare, as Massachusetts discovers not only that it cannot afford to subsidize private health insurance companies, but that the system has no way to re-direct resources where they are needed, places like primary care offices and emergency departments.
Can we reform our health system in a way that recognizes the efforts already underway in our EDs, that won’t further alienate ED MDs, nurses and staff, that can begin to shift resources where our patients and communities need them most?
We need a proposal for reform that will take into account the interlocking issues of costs, quality, individual choice of physician or hospital and woeful disparities in care — in addition to the need to cover the uninsured and underinsured. It must not only be comprehensive in terms of the services provided each patient, but also in the capacity to shift resources to where they are needed. In 2008 the United States of America will spend nearly $7,800 per capita, $2.4 trillion, 16.6 % of GDP on health care. More than half of U.S. health spending already comes from government sources. And our nation spends far more per capita than any other (70% more than the median of OECD nations). More than enough resources are already in the system for a national health program. Yet health outcomes in the United States lag shamefully behind other nations.
Administrative waste accounts for at least $350 to $700 billion in the present system. Compare the Medicare overhead cost of 3% to private health insurers’ overhead which is 22%. These hundreds of billions of dollars spent on administration, advertising, handsome executive salaries and corporate profits, should be spent on health care.
The proposal by Physicians for a National Health Program has been endorsed by over 14,000 doctors. “The Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance,” was published in JAMA in 2003. It starts from the ideas that (1) health care is a human right; (2) patient autonomy, the right to choose any licensed health care professional, must be protected; (3) profit-making has no place in the delivery of health care and (4) “In a democracy, the public should set overall health policies. Personal medical decisions must be made by patients with their caregivers, not by corporations or governments.”
The single payer proposal would not make our hospitals, clinics and offices government property.
HR 676, a bill in Congress, would establish a single payer health care system by expanding a greatly improved Medicare system to cover everyone. It would restore a patients’ right to choose healthcare providers and limit insurance company input into medical decisions. HR 676 would cover everyone for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, chiropractic and long term care. It would end deductibles and co-payments and could save billions annually by reducing
overhead. It would convert for-profit health facilities to not-for-profit status, over a period of years.
When single payer financing has been studied (for example in California, Colorado, Georgia and many other states, as well as by the Congressional Budget Office in the 1990s) it emerges consistently as the only proposal with a means to reduce costs. One funding mechanism proposed recently in California would keep all existing government funding and add a 3 to 4% income tax on individuals and a 7 to 8% payroll tax on employers, with additional taxes on selfemployed business income, investment income and high incomes. For many working people and for employers who provide excellent health insurance, these taxes would be a significant savings compared with present premiums, co-pays for visits, labs and drugs, deductibles and other out-of-pocket expenses.
Under the proposal, physicians would be paid by the single payer on a fee-forservice basis or receive salaries and incentives through their institutions or physician groups, which in turn would be funded by the national health insurance program. Because doctors would not become employees of the government, but would know what to expect from the single payer, their administrative burden would be reduced.
Hospital services would be paid on a global rate based upon community needs. Community needs are the proper subject of public evaluation and debate in a democracy. The Certificate of Need process is an example of how community need defines healthcare capacity, thus limiting excess expenditure for unnecessary services and driving up healthcare utilization without improvement in quality. The certificate of need process in New York State has boasted superior cardiac surgery outcomes, compared with other States, at lower costs.
The single payer proposal would not make our hospitals, clinics and offices government property. But it would vastly empower existing quality improvement efforts by placing decisions about the allocation of health resources in the public domain. In this way, it is a transitional demand - a demand that would base future progress upon the excellent people and institutions we have now.
We know that single payer systems work in other nations, yet the United States spends much more yet lags far behind in health outcomes. We also know that the way to decrease cost is to share the risk as completely as possible, “Everybody in, nobody out.” But another crucial element of “everyone in, nobody out” we must see are the intolerable disparities in health care our system of private health insurance has cultivated in America, rural vs. urban, wealthy vs. poor, black vs. white, immigrant vs. native-born and so on. Only a federal reform will bring a starting point that is both practical and just.
Every emergency room must be staffed for the disaster that could come, not the minimum for the usual circumstances. Under a national health insurance program emergency medicine physicians and nurses would at last have the appropriate forum in which to explain to society their contribution - and to make a case for sufficient resources, including EMS networks, the need for on-call specialists, the need to expand primary care, the need to reduce wait times and improve quality. Viewed this way, the single payer alternative appears the best means for our profession to take proper social responsibility for the care of our communities.
Everyone uses the ED at one time or another. Proper resources for our EDs will improve us all. This must be recognized. A single payer program is only reform that can begin to do so.
Editor’s Note:
This essay was solicited from Dr. Coates, a strong proponent for single payer — universal access health care. It is written from the perspective of a primary care physician viewing the interaction between limited access to care and emergency medicine. There are many who believe that within 10 years, healthcare will not be structured or financed as it is presently. As we move forward, there is increasing attention being paid to universal healthcare. But there is also considerable concern regarding the consequences of single payer healthcare to a system that, for all of its failings, works well enough for many people (those with simple medical needs and who are well-insured). Yet we as emergency physicians live in a world that experiences a critical lack of access to primary care and specialty services. We also exist in a world dominated by the consequences of failure to effect healthcare changes when a change has clear advantages. To many, this appears to be the result of a system that exists to serve itself and not our population. Universal healthcare appears to successfully address these challenges in many developed countries. However, comparing the healthcare systems of the United Kingdom, Canada or France (with their culturally homogeneous populations of 30 to 50 million) with our healthcare system (servicing 300 million culturally diverse) may be problematic. There will be many voices influencing the shape of the future structure of our healthcare delivery system. It is important that each of us understand the realities of this multifaceted issue. It is also important that we speak from the standpoint of improving the health of our communities.