Three days ago, I posted a letter signed by many health and social policy experts concerning individual mandates. I happily signed because the mandate issue has been accorded such undue centrality to the health reform debate. Both the Obama and Clinton plans will leave some number of Americans without coverage. No one can say how close these plans will come to universal coverage, because the devil is in the political and administrative details--details likely to be set by a future Congress negotiating with the next president.
As I post this, I encountered a new paper by Jonathan Gruber which argues the necessity of a stringent mandate. He is an excellent economist. So I presume that he has run the numbers right for the comparisons he makes. However, he presumes a stringent set of mandate policies, while his proxy for the Obama plan presumes that little is done to deter free-riding. As Senator Obama noted in the last debate, his proposal can be designed to make free-riding less attractive.
As Dr. Gruber himself notes, the main question remains whether our nation has the political will and administrative acumen to implement a mandate that imposes more than nominal penalties on people who do not buy coverage. As a volunteer for the Obama campaign, I have spoken to many primary voters. Whatever is believed by health policy researchers, my sense from these conversations is that even core Democratic voters don't much like mandates.
The dilemma is underscored in today's Times,
A group of doctors and health policy analysts, including a number of Obama advisers, pointed out in a letter released Thursday that Massachusetts, the only state with an insurance mandate, has thus far failed to enroll nearly half of its uninsured despite imposing a modest first-year tax penalty of $219 (the fine increases significantly this year). Because the Massachusetts program is less than a year old, it is not yet possible to fully judge the effectiveness of its mandate.
Senator Clinton herself seems to have doubts. Today's New York Times has a story entitled "In Health Debate, Clinton Remains Vague on Penalties." This is significant. If she is nominated, Republicans will press this argument hard in November and beyond.
I am not particularly invested in the mandate debate. If mandates were politically and administratively costless, I would favor them. If not, I personally would emphasize other things.
I have mildly benefitted from the hubbub, which has brought more than 1,000 new visitors to my blog. This newfound success illustrates the very problem I lament. If the mandate issue is so overblown, what's being crowded out? And universal coverage itself is only one aspect of health reform. Getting everyone, or nearly everyone, covered is only one key input required to fix the many serious problems of our healthcare system.
Here is one other issue I would like to see discussed: our national crisis in emergency care.
By all accounts, our patchwork of emergency care services is in trouble. Given the times in which we live, homeland security experts recommend increased surge capacity in case of a natural or intentional mass casualty event. Yet many emergency departments (EDs) have closed or are in financial trouble. Over the past decade, ED visits have significantly increased, while the number of EDs has declined by almost 40 percent. Almost all trauma centers operate at or above capacity. Practices once considered anomalous, such as ambulance diversion and the extended "boarding" of ED patients in hospital hallways, are now commonplace.
Long waits reflect a cruel catch-22. Right now, services to a very large population of unprofitable patients are effectively rationed by the delays and unpleasantness associated with ED care. No single hospital has the ability, or really the incentive, to address these concerns. What urban hospital wouldn't think twice about making ED services more pleasant and quick if these very improvements would cause even greater numbers of uninsured patients to flock to one's doors?
Whatever the causes, waiting time are growing. This is always unpleasant and is sometimes life-threatening. As one distinguished physician testified to Congress, "we simply can't always get to everyone. And if we can't get to you, we can't save your life." Last year in Los Angeles's Martin Luther King Jr.-Harbor Hospital, relatives of one waiting ED patient became so desperate that they called 911. Paramedics refused to come, and the patient died an agonizing death from a perforated bowel. Less dramatic tragedies are disconcertingly common. A surprising number of ED staff report first-hand knowledge of a patient death due to delayed care.
Across the political spectrum, commentators cite those crowded EDs to support their own prior views. Frustrated providers lament the fecklessness of patients, some number of whom make inappropriate or avoidable use of ED services. President Bush, disparaged the import of the coverage problem, with the assertion: "I mean, people have access to health care in America. After all, you just go to the emergency room."
This is a breathtaking oversimplification. ED providers address acute conditions and then link patients with other providers. They are not positioned to provide ongoing care or to provide key services provided by specialists or in primary care. EDs are obliged to treat your emergent condition. They are not obliged to admit you to their hospital. They can--and increasingly do--stabilize undesired patients and hustle them off by ambulance to a nearby public hospital or another charity provider.
EDs are certainly not obliged to forgive their bill. Jonathan Cohn's book Sick describes Dickensian conditions at my own county courthouse, whose docket is clogged with medical debt cases. In most of these cases, hospitals are suing low-income patients. The hospitals rarely get what they are owed. That's not even the point. No hospital wants to be viewed as a sap in a city filled with uninsured people.
Liberals note the same inefficient use of ED services. They attribute the crowding to poor access to care. Many commentators suggest that a more humane system would save a lot of money by that expands primary care will save money by reducing costs associated with ED visits.
Liberals are right about what's needed for humane care, but all sides oversimplify a messy reality. The entire debate takes much granted troubling features of our current financing and care delivery system. Here are three fundamental points most people miss:
1. "Inappropriate" ED visits are harder to define and more difficult to prevent than we generally assume.
Listening to the 2008 campaign, one might believe that uninsured patients seeking primary care are responsible for our overstretched and overcrowded emergency departments. Actually, lack of coverage is only one of many reasons for these problems. If we enacted universal coverage, but made no other change to the health care system, there's no reason to expect those crowded ED waiting rooms to be much less full.
Patients have a huge range of medical and social motivations for relying on the ED for care that we policy wonks would like to see delivered elsewhere. Only some of these motivations are addressed through improved coverage. (And, of course, improved health insurance coverage would allow some patients to access the ED who now avoid these services due to cost concerns.) Many of the low-income folks dozing off in waiting room chairs are already insured.
Some patients have poor personal relationships with their primary doctor. Others don't like to wait for scheduled appointments. Others are willing to wait hours because they believe they get better care at a major hospital than at their local clinic. Some just need a warm place to sit. Others have urgent medical, financial, or family needs that might not ostensibly require ED services, but they know that the people who staff the ED can provide effective help.
Data from the RAND Health Insurance Experiments suggest that charging people copayments will reduce ED use. Only one problem: There is little evidence that people can distinguish necessary from unnecessary ED use. Michigan researcher Kyle Grazier and I once studied a health plan which charged a 50% copay for psychiatric emergency services. Would you want your schizophrenic or bipolar child to be thinking about that copay when she worries that she might require such help? Would you want your father to consider such financial issues when he wakes up at 3am with chest pain?
2. We aren't likely to save much money discouraging or forestalling inappropriate ED use.
Many Americans believe that ED care is extraordinarily costly and inefficient, and that we could save large amounts of money if we could divert ED patients into primary care. These arguments are plausible. Millions of people have had the experience of requiring emergency care for some relatively minor ailment, only to receive an astronomical bill. If an ED charges you $700 to treat a minor urinary tract infection, who can deny that there must be some colossal inefficiency in providing such care.
In fact, these arguments reflect misconceptions about how EDs are financed, and what it actually costs to provide emergency care. The charge is indeed startling when you use an ED after a minor sports injury or to treat a minor illness. Much of your bill has nothing to do with the needle and thread required to sew you up or the specific supplies needed for your throat culture. It is, instead, your contribution to the fixed costs of having those ED personnel and facilities always available to treat you.
Studies by Robert Williams and others suggest that it costs the typical ED surprisingly little to provide nonurgent care. In economic language, the marginal cost of these ED visits is pretty small--less than $100 as of ten or fifteen years ago. This analysis leaves some things out, including the economic value of delay imposed on other patients. Still, discouraging nonurgent visits is likely to have a small impact on the true costs of providing emergency care. Of course, your insurer wants you to avoid the emergency department, because it has no special desire to subsidize the ED's costs of doing business. From a wider perspective, someone has to pay if we want the ED to remain open.
And the financial nightmare facing many EDs does not arise from inappropriate use. It arises from thousands of all-to-appropriate visits by uninsured or underinsured patients who require costly services and who may then require hospitalization. Many hospitals regard the ED as a chink in their armor through which they are forced to admit unprofitable patients and provide uncompensated care.
Improved insurance coverage would greatly improve this situation--not by reducing inappropriate ED use, but by lessening the financial burdens on hospitals associated with emergency care. This will greatly improve the quality and the dignity of emergency care. Tthere is no particular reason to believe that this will reduce public expenditures. I suspect and even hope that the opposite is true. Improved coverage and care will raise expenditures, because these changes will encourage more patients to seek more, and more appropriate, services in the ED and elsewhere than they now receive.
3. The right policy questions concern how to improve delivery and financing of ED care (and primary care, too). We should not press too hard to discourage unnecessary or inefficient ED use.
No matter how unpleasant and undignified emergency care seems to be, the patients keep coming. This understandably frightens the chief financial officer of an overburdened public hospital. Yet from a broader perspective, this is a great opportunity. James Gordon notes that EDs may be the only places people know they can go, 24 hours per day, 365 days per year, with some reasonable expectation that a professional will address their needs. That's one reason why social service and public health practitioners regard EDs as unique resources to find and serve people in great need. If we accept what is probably inevitable--the patients will keep coming--we can sensibly investigate how EDs can be operated and financed to meet patient needs.
Unfortunately, this is a marked departure from the training and socialization of many ED providers. Trained to treat acute illness and injury, many ED doctors and nurses complain that they spend their days providing various services that have nothing to do with what they were trained to do. We in the public health community want ED staff to screen patients for domestic violence, sexually-transmitted infections, substance use disorders, safe gun storage in the home, homelessness, maternal depression, and a lot more. The list keeps growing.
Doctors and nurses are right to complain, but the problem doesn't rest with the public health community or with the patients. ED facolities must adapt to serve the needs of the patients who actually use them, even if these patient needs depart from the hopes and expectations of ED providers.
Under a different operating model, EDs would include more social workers and other staff to address a wide range of important personal and family needs. A healthcare system focused on public health would reimburse or directly subsidize many of these services through government, rather than expecting hospitals to provide these unprofitable services for free.
Under a different financing model, EDs would be less fearful of the burdens associated with uncompensated care. EDs have always needed, and have often received, state and federal help to meet these burdens. For all sorts of reasons, the need for such support would continue even after a successful health reform. We need to do much more of this, and to provide more explicit subsidies when we ask EDs to accomplish important public tasks.
To take one example, 2006 guidelines by the Centers for Disease Control and Prevention recommend broad-based HIV screening of most ED patients. Most ED providers support the basic idea behind these guidelines, given evidence that many persons living with HIV are not diagnosed until they are already suffering opportunistic infections or other serious problems. Yet the guidelines have met real resistance because they were not accompanied by additional resources such as Medicaid and Medicare reimbursements for screening HIV tests. Such unfunded mandates are quite common, and are often ineffective.
I'm not sure that improving our emergency care system will make big-city emergency departments much less crowded or efficient. I do believe that we can make our emergency care system much more stable, humane, and competent than it now is. We don't actually need universal coverage to address the financial crisis in emergency care. We do need to reduce the scale of the problem. Our ED care network will crumble if it continues to bear the most prominent burden in treating 47 million uninsured people. Many patients and providers would argue that it already has.